Credentialing Standards   /   February 2019

The CMS Preclusion List: What you need to know

The CMS Preclusion List: What you need to know

By now, we’re sure you’ve heard about – or have already been impacted by – CMS’ new list of preclusions, which will disqualify some prescribers and providers from receiving payment for Medicare Advantage services. But what does it all mean? And what important deadline is fast approaching?

We’ve got some answers below! For more information on how we can help your team through this transition, contact us.

Let’s start with the basics: What is the CMS Preclusion List?
CMS has created the Preclusion List to replace Medicare Advantage (MA) and prescriber enrollment requirements. Prescribers and providers on the list are disqualified from receiving payment for Medicare Advantage items, services, or Part D drugs provided for Medicare beneficiaries. The list contains prescribers, individuals or entities who:

  • Are currently revoked from Medicare, are under an active re-enrollment bar, and CMS has determined that the underlying conduct that led to the revocation is detrimental to the best interests of the Medicare program
  • Have engaged in behavior for which CMS could have revoked the prescriber, individual or entity to the extent applicable if they had been enrolled in Medicare, and CMS determines that the underlying conduct that would have led to the revocation is detrimental to the best interests of the Medicare program.

Diving deeper: What kind of behavior revokes a prescriber and gets them on the Preclusion List?

  • Felony convictions
  • Office of Inspector General (OIG) exclusions
  • Other adverse actions deemed not to be in the best interests of Medicare

Who will be affected?

  • Medicare Advantage and Part D plans
  • Providers on the Preclusion List
  • Patients who have subscriptions, items or services provided by doctors on the Preclusion List

What does the Preclusion List look like?
The Preclusion List is an Excel document that contains the following data on precluded providers:

  • Provider Name
  • Business Name
  • Practice Type (General/Speciality)
  • National Provider Identifier (NPI)
  • Employer Identification number (EIN)
  • Date of Birth
  • Address
  • Exclusion Date
  • Claim Rejected Date (if applicable)
  • Reinstatement Date (if applicable)

Most importantly: When will The Preclusion List be effective?
January 1, 2019 – CMS made the first iteration of the Preclusion List available to Part D sponsors and the Medicare Advantage (MA) plans.

April 1, 2019 – MA and Part D plans will not begin editing claims until April 1, in order to allow 30 days for plans to review the Preclusion List and inform patients by mail if they have received a healthcare item, service or prescription drug in the past from a provider that has been added to the Preclusion List.

Notifications allow for a 60-day period before Part D sponsors reject a pharmacy claim (or deny a beneficiary request for reimbursement) for a Part D drug that is prescribed by an individual on the Preclusion List, and MA plans deny payment for a health care item or service furnished by an individual or entity on the Preclusion List.

Finally: The Bottom Line
Essentially, the Preclusion List is another standard that Medicare Advantage and Medicare Part D plans have to check off when doing their credentialing so that patients can receive the best care at the best costs.

CredSimple is here to help. If you have questions about the Preclusion List and how to implement it, contact us.

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