Appealing a Medicare Provider Enrollment Denial

Texas Attorneys Handling Denials, Reconsiderations, and Appeals for Providers and Suppliers Nationwide

Did Medicare deny your practice, agency, or supplier application? The reasons are not always easy to pin down. Anything from a felony conviction to a simple punctuation error can get your application rejected.

Our Houston-based legal team knows the enrollment process is demanding enough without a denial complicating it further. CMS does not always spell out its requirements clearly. You can submit what looks like a complete, correct application, then learn a specific requirement existed only when the denial or rejection notice cites it as the reason.

At Hendershot Cowart P.C., we handle the initial redetermination request on your behalf, so it is filed correctly and on time.

On This Page

• Is This Page for You?
• The Medicare Enrollment Process
• What Happens When Your Medicare Enrollment Application Is Denied or Rejected?
• What To Do If Your Enrollment Application (CMS-855) Is Rejected
• Common Reasons for Medicare Enrollment Denial
• Appealing a Medicare Enrollment Application Denial
• What's Changing: CMS's Proposed Enrollment Denial Rules
• Knowledgeable Assistance with Medicare Enrollment Denials, Reconsiderations, and Appeals

Hendershot Cowart P.C. has been nationally recognized for our work in health and medical law, and actively serves clients nationwide in Medicare matters. Call (713) 783-3110 to speak with a lawyer.

Is This Page for You?

This page covers Medicare provider and supplier enrollment denials under the CMS-855 process, not personal Medicare eligibility or coverage denials.

If you are a Medicare beneficiary whose personal Medicare coverage or benefits have been affected, contact Medicare directly at 1-800-MEDICARE (1-800-633-4227) or visit medicare.gov for assistance with your individual coverage.

The Medicare Enrollment Process: Some Background

CMS has placed as much attention on scrutinizing providers and suppliers who seek enrollment in Medicare as they do on matters of Medicare exclusion, billing privilege revocations, and other enforcement tools for cracking down on waste, fraud, and abuse. The result is a difficult and daunting credentialing process, and one rife with potentially problematic areas – especially for those with blemishes on their record.

Medicare enrollment was not always this demanding. After federal fraud crackdowns revealed how often unqualified or dishonest applicants were approved, the Centers for Medicare and Medicaid Services (CMS) tightened its screening considerably, most notably through a 2006 final rule that expanded enrollment requirements and created the framework CMS still uses to deny applications and revoke billing privileges.

Today, any provider or supplier that wants to bill Medicare, whether for services furnished to a beneficiary or for items and equipment, must first enroll. The process centers on the Medicare enrollment application, commonly known as the CMS-855, submitted on paper or electronically through PECOS, the Provider Enrollment, Chain, and Ownership System. 

Which version of the form you file depends on your provider type:

• CMS-855I for individual practitioners, such as physicians, physician assistants, and nurse practitioners
• CMS-855S  for DMEPOS suppliers
• CMS-855B for group practices and most other suppliers
• CMS-855A for institutional providers, including hospitals and home health agencies
• CMS-855R when an individual practitioner reassigns billing rights to a group or organization

The application collects identifying information, licensure and certification data, and practice location details, and it covers five kinds of transactions: 

1. Enrolling for the first time;
2. Reporting a change in ownership;
3. Revalidating existing enrollment information;
4. Reactivating billing privileges after deactivation; and 
5. Reporting a change to information already on file. 

Once submitted, CMS or its contractor reviews the application to confirm the information and determine whether the applicant meets every applicable federal requirement. That review is where a rejection, denial, or approval decision gets made.

What Happens When Your Medicare Enrollment Application Is Denied or Rejected?

Whether you are a prospective supplier or provider seeking enrollment for the first time, or are seeking enrollment following a revocation or exclusion, your application will result in one of three actions:

1. Billing privileges will be granted;
2. The application will be rejected; or
3. The application will be accepted, but billing privileges are denied.

A rejection means CMS never reviewed the substance of the application at all, usually because required information or documentation was missing. The remedy is procedural: correct the deficiency and resubmit a new application. 

A denial means CMS reviewed a complete application and determined, on the merits, that the applicant does not meet Medicare's enrollment requirements. That distinction carries real consequences. A rejection generally cannot be appealed. A denial can.

What To Do If Your Enrollment Application (CMS-855) Is Rejected

If an application is incomplete and applicants fail to provide needed documentation or information within 30 days of being notified, a CMS contractor has the authority to reject the application. However, the contractor also can work in good faith with applicants to extend the time period for furnishing needed information and resolving the matter.

If an application is formally rejected, applicants must re-initiate the enrollment process, complete a new CMS-855 form, and re-submit all supplementary documentation. Providers or suppliers that have their enrollment applications rejected do not have the right to appeal.

Common Application Errors

Many enrollment denials and rejections trace back to preventable mistakes on the application itself. Reviewing these before submission can save months of delay.

• Filing the wrong CMS-855 form. Individual practitioners use the CMS-855I, group practices and most suppliers use the CMS-855B, institutional providers such as hospitals and home health agencies use the CMS-855A, and DMEPOS suppliers use the CMS-855S. Submitting the wrong version restarts the review process.
• Missing a signature or the required certification statement. CMS also rejects applications signed more than 120 days before the Medicare contractor receives them or signed by someone not authorized to sign on the provider's behalf.
• Mismatched identifying information. Your National Provider Identifier, tax identification number, legal business name, and practice address must be consistent across CMS, IRS, and NPPES records. Even a small discrepancy can trigger a rejection or delay.
• Missing supporting documentation. License copies, accreditation records, a surety bond for DMEPOS suppliers, and other required attachments must accompany the application, not follow later.
• Submitting a paper application in pencil, or by fax or email when not otherwise permitted. These formatting requirements are easy to overlook but treated strictly.

None of these issues alone means an application will be denied outright. Most trigger a rejection with a chance to correct and resubmit. But repeated or uncorrected errors can escalate into a denial, which carries appeal rights and consequences of its own.

Common Reasons for Medicare Enrollment Denial

There are a number of reasons why a provider or supplier may be denied enrollment in Medicare. Some examples include:

• Submission of false or misleading information on the Medicare enrollment application to gain enrollment
• Non-compliance with requirements and failure to submit an acceptable CAP (corrective action plan)
• The applicant or any other official or employee within the organization is excluded from participating in federal healthcare programs, or has been placed on payment suspension
• Failing to pass an on-site review
• Existing Medicare debt or overpayment
• Convictions for certain crimes, including any conviction within the past 10 years involving a felony crime (i.e., crimes against a person), a felony which places beneficiaries or the program at risk (i.e., criminal negligence or misconduct), and certain financial crimes (i.e., tax evasion, insurance fraud, and embezzlement).

The strategy for responding to an enrollment denial depends largely on the underlying reason. If, for example, an applicant was denied due to the adverse actions of a managing employee or anyone in the practice or company, CMS can reverse the denial if applicants submit proof that they terminated relationships with those individuals within 30 days of receiving a denial notice. For denials based on other reasons, applicants have the right to appeal.

A denial based on false or misleading information carries an additional consequence beyond the denial itself. CMS can bar the applicant from reapplying to Medicare for up to 10 years. This reapplication bar is separate from, and can be pursued alongside, the appeals process described below.

Appealing a Medicare Enrollment Application Denial

Medicare enrollment denials by CMS are "initial determinations" subject to an administrative appeals process, triggered when CMS mails you a notice of initial determination. That notice states the reasons for the denial, its effect, and your right to appeal.

If your denial was based on non-compliance, you may have 30 days from the date you receive the notice to submit a corrective action plan (CAP). A CAP is an early intervention option, not an argument that CMS was wrong, and if you have that option, it needs to be complete and accurate the first time. Filing a CAP does not prevent you from also pursuing the appeals process below.

The following four-stage appeals process covers determinations that affect participation in Medicare, including enrollment denials, enrollment revocations, and compliance enforcement actions:

1. Reconsideration. You can submit a written request for reconsideration within 60 days of receiving your determination notice (receipt is presumed to be five days after the date on the notice). Your request must detail the findings you disagree with, your reasons why, and any supporting documentation. A hearing officer who was not involved in the initial determination will review your request and mail you a reconsideration determination.
2. ALJ hearing. If your reconsideration determination is unfavorable, you can request a hearing before an administrative law judge (ALJ) within 60 days, and your request must identify the specific findings you dispute and explain why they're wrong. Hearings are typically held by phone or videoconference, though you can request one in person, and the ALJ may decide your case on the written record alone if there's enough information without live testimony. Any evidence you didn't submit earlier has to clear a “good-cause standard” before the judge will consider it, meaning the judge will want to know why you're introducing it now instead of at the reconsideration stage. For this reason, building a complete record early matters. The judge is required by law to issue a written decision within 180 days of the date the appeal was filed.
3. DAB review. If the ALJ hearing produces another unfavorable decision, the next stage is review by the U.S. Department of Health and Human Services (HHS) Departmental Appeals Board (DAB). You must file your request within 60 days, and it must identify the specific findings of fact or legal conclusions you disagree with and explain why the decision is wrong. The DAB reviews the hearing record along with any additional evidence submitted during review, and it can affirm, modify, or reverse the ALJ's decision, or remand the case back for further proceedings. The DAB must decide within 180 days of your request, and its decision is the final administrative determination within HHS.
4. Judicial review. As a final step, you can file a civil action in federal court within 60 days for judicial review.

Note: The Medicare appeals process differs significantly between payment claims disputes and enrollment denials. Learn more about the five-part appeals process for Medicare claims payments, including disputes over coverage decisions and payment amounts.

What's Changing: CMS's Proposed Enrollment Denial Rules

On July 6, 2026, CMS proposed a sweeping set of changes to Medicare provider enrollment rules, including several that would directly affect how applications are denied and what happens afterward. These changes are proposed, not final, but the direction is clear enough that applicants and their advisors should understand what may be coming.

• A longer reapplication bar, for any reason. Today, the 10-year reapplication bar applies only to denials based on false or misleading information. CMS wants to extend that same bar to any denial reason, at CMS's discretion.
• The false-or-misleading-information ground would expand. It is currently limited to the enrollment application itself, submitted to gain enrollment. CMS wants to reach any enrollment-related form or supporting documentation, regardless of why it was submitted.
• More people could trigger a denial. The Medicare debt, payment suspension, and program termination or license action grounds currently reach the applicant and its owners. CMS wants to extend them to managing employees, managing organizations, and anyone else with a business or financial relationship with the applicant.
• New denial grounds altogether, including certain misdemeanor convictions, sharing a practice location with a provider whose enrollment was revoked or denied, and attempting to enroll under another party's identity.

Comments on the proposed rule were due August 31, 2026. Read our full breakdown of the proposed changes.

Knowledgeable Assistance with Medicare Enrollment Denials, Reconsiderations, and Appeals

Because enrollment in Medicare and the ability to bill federal programs can be critical to the financial health of your healthcare practice or medical supply business, seeking the help of experienced attorneys when appealing a denial from Medicare can help you make the most of your rights and limited opportunities to rectify a difficult situation.

Hendershot Cowart P.C. forms Texas medical practices, and we defend them when regulators, payers, or other third parties come calling. When Medicare denies your enrollment application, that same experience shapes every redetermination request, reconsideration, and appeal we file on your behalf.

To speak with an attorney about your case and options, call (713) 783-3110 or contact us online.