CMS Preclusion List

What is it?

A list of providers and prescribers who are precluded from receiving payment for Medicare Advantage items and services or Part D drugs.

Who’s on it?

Prescribers and individuals or entities that fall within any of the following categories:

  1. Currently revoked from Medicare, under an active reenrollment bar, and CMS has determined that the underlying conduct that led to the revocation is detrimental to the best interests of the Medicare Program
  2. 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.

So, what does this mean?

A prescriber, individual, or entity may be added to the CMS preclusion list because their Medicare billing privileges have previously been revoked or they are currently under a reenrollment bar.

  1. Part D sponsors will be required to 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.
  2. MA plans will be required to deny payment for a health care item or service furnished by an individual or entity on the Preclusion List.