Medicare Billing Privilege Revocation and Re-Enrollment Bans: How to Appeal Before It Is Too Late

Revocation of Medicare billing privileges is one of the most serious administrative actions the Centers for Medicare & Medicaid Services (CMS) can take against a provider or supplier. A revocation ends the provider's ability to bill Medicare, terminates any provider agreement, and is usually followed by a re-enrollment bar that can last for years. A revocation can also lead to placement on the CMS preclusion list, which affects Medicare Advantage and Part D payments, and to termination from state Medicaid programs.

Revocations have become more common. CMS reported revoking the Medicare billing privileges of 5,586 providers and suppliers in 2025, and in connection with the 2026 National Health Care Fraud Takedown, the Department of Justice reported that CMS revoked billing privileges for 1,403 providers. CMS has also proposed expanding its revocation authority in its calendar year 2027 Home Health Prospective Payment System proposed rule.

The appeal process for revocations has strict deadlines and important procedural rules. Most notably, providers generally have 60 days to request reconsideration, and the reconsideration request is often the only opportunity to submit evidence in the administrative appeal. Missing a deadline or failing to submit evidence on time can mean losing the chance to challenge the revocation.

This article explains how Medicare revocation works, the common grounds for revocation, how re-enrollment bars work, the corrective action plan and reconsideration options, the steps in the appeal process, and practical advice for responding before it is too late. It is educational and not legal advice. Providers facing revocation should consult experienced legal counsel promptly.

What Is Medicare Billing Privilege Revocation?

Under 42 CFR 424.535, CMS may revoke a provider's or supplier's Medicare enrollment and billing privileges for a range of reasons. CMS materials describe revocation as the removal of billing privileges and termination of the provider or supplier agreement.

Revocation is different from deactivation. Deactivation, under 42 CFR 424.540, is an administrative pause in billing privileges, often for reasons such as failing to respond to a revalidation request or not billing for an extended period, and it can be resolved by submitting a complete enrollment application. Revocation is a more serious action that removes the provider from the program and generally includes a re-enrollment bar.

Revocation is also different from denial. A denial, under 42 CFR 424.530, applies to an enrollment application. CMS manual instructions state that re-enrollment bars apply only to revocations, not to denials.

Common Grounds for Revocation

Under 42 CFR 424.535(a), grounds for revocation include, among others:

• Noncompliance with enrollment requirements, under 424.535(a)(1).

• Exclusion or debarment of the provider or certain affiliated individuals.

• Certain felony convictions within the preceding 10 years.

• False or misleading information on the enrollment application, under 424.535(a)(4).

• A finding during an on-site review that the provider is not operational or is not meeting Medicare requirements.

• Misuse of billing numbers.

• Abuse of billing privileges, including a pattern or practice of submitting claims that fail to meet Medicare requirements, under 424.535(a)(8).

• Failure to report required changes in enrollment information.

• Failure to document or provide CMS access to documentation, such as orders, certifications, or referrals.

• Billing for services from a non-compliant location.

CMS has also proposed, in its CY 2027 Home Health Prospective Payment System proposed rule, additional and expanded grounds, including allowing revocation based on false or misleading information on any CMS or Medicare enrollment-related form, revocation of hospices, home health agencies, and DMEPOS suppliers that fail to comply with change in majority ownership requirements, and revocation of enrollments that present a high risk of fraud due to location in a limited geographic area with an excessive number of providers. Providers should monitor whether these proposals are finalized.

Effective Dates and Immediate Consequences

The effective date of a revocation depends on the basis. For many revocations, the revocation becomes effective 30 days after CMS or its contractor mails the notice. For certain grounds, such as felony convictions, license suspension or revocation, exclusion, or a determination that the practice location is not operational, the revocation may be effective on the date of the underlying event, which can be earlier than the notice. CMS has also proposed expanding the circumstances in which revocations can have retroactive effective dates.

Consequences of revocation include:

• Loss of Medicare billing privileges. Claims for services furnished after the effective date are not payable.

• Termination of the provider agreement for certified providers and suppliers, under 42 CFR 424.535(b).

• A re-enrollment bar under 42 CFR 424.535(c).

• Possible revocation of other enrollments. Under 42 CFR 424.535(i), if a provider's enrollment is revoked, CMS may revoke the provider's other enrollments.

• Possible placement on the CMS preclusion list, which prevents payment for Medicare Advantage items and services and Part D drugs.

• Possible Medicaid termination. Under 42 CFR 455.416, state Medicaid agencies must terminate the enrollment of providers terminated by Medicare or another state Medicaid program, subject to the regulation's terms.

• Potential overpayments for claims paid after the effective date.

Understanding Re-Enrollment Bars

Under 42 CFR 424.535(c), a provider whose billing privileges are revoked is barred from participating in Medicare from the effective date of the revocation until the end of the re-enrollment bar. Key points include:

• The re-enrollment bar generally lasts from 1 to 10 years, depending on the severity of the basis for revocation.

• CMS may impose a longer bar, up to 20 years, if a provider is revoked a second time, and may add years to an existing bar in certain circumstances, such as when a provider attempts to re-enroll under a different name or identity.

• According to a 2026 Departmental Appeals Board decision, the bar to re-enrollment begins 30 days after CMS or the Medicare Administrative Contractor (MAC) mails the notice of the initial determination to revoke.

• CMS manual instructions describe an exception under which no re-enrollment bar is applied when the revocation is based solely on a failure to respond timely to a revalidation request or other request for information, and certain conditions are met.

Importantly, the Departmental Appeals Board has held that the duration of a re-enrollment bar is not an appealable initial determination. In other words, providers can appeal the revocation itself, but generally cannot appeal the length of the bar. This makes it even more important to challenge the revocation on its merits when grounds exist.

Your Appeal Options: Corrective Action Plan and Reconsideration

Under 42 CFR 405.803 and 424.545(a), a provider or supplier may appeal a revocation by following the procedures in 42 CFR Part 498. There are two initial options, which serve different purposes.

Corrective Action Plan

A corrective action plan (CAP) gives a provider an opportunity to demonstrate compliance by correcting the deficiencies that led to the revocation. CMS materials explain:

• A CAP may only be submitted in response to a revocation for noncompliance under 42 CFR 424.535(a)(1), or in response to a denial of enrollment under 42 CFR 424.530.

• The CAP must be submitted within 30 calendar days after the postmark date of the revocation letter, according to CMS model letters.

• A provider has only one opportunity to correct all deficiencies through a CAP.

• The CAP should provide evidence that the provider is in compliance with Medicare requirements.

• The denial of a CAP is not an initial determination under Part 498 and does not give rise to further appeal rights.

Because a CAP denial cannot be appealed, providers should not rely on a CAP alone if they also believe the revocation was wrong. In many cases, providers consider filing both a CAP and a reconsideration request where permitted, with advice from counsel.

Reconsideration

A reconsideration request allows a provider to demonstrate that the initial determination was in error at the time it was made. Key rules from 42 CFR 498.22 and CMS manual instructions include:

• The request must be submitted in writing within 60 days from receipt of the notice of initial determination.

• The date of receipt is presumed to be five days after the date on the notice, unless there is a showing that it was received earlier or later.

• The request must state the issues or findings of fact with which the provider disagrees and the reasons for disagreement.

• The request must be signed by the individual provider or an authorized or delegated official.

• Depending on the type of revocation, the request is filed with the MAC or with CMS's Provider Enrollment and Oversight Group, as specified in the notice.

• A hearing officer who was not involved in the initial determination or the CAP review conducts an independent, on-the-record review and generally issues a decision within 90 days.

• The reviewer may not introduce new revocation reasons or change the reasons listed in the initial determination.

• Failure to timely request reconsideration is deemed a waiver of all rights to further administrative review.

The Most Important Rule: Submit Your Evidence Now

CMS revocation notices state that if a provider has additional information it would like a hearing officer to consider during reconsideration, or an administrative law judge to consider during a hearing, the provider must submit that information with the reconsideration request. CMS describes this as the provider's only opportunity to submit information during the administrative appeals process, unless an administrative law judge specifically allows otherwise under 42 CFR 498.56(e).

This rule means the reconsideration request should be treated as the main evidentiary submission for the entire administrative appeal. A short request with a promise to send documents later may leave the provider without the evidence it needs at later stages.

Further Appeals After Reconsideration

If the reconsideration decision is unfavorable, the provider may continue through the Part 498 appeal process:

• Administrative Law Judge hearing. A provider dissatisfied with a reconsidered determination may request a hearing before an Administrative Law Judge (ALJ). According to CMS manual instructions, the request must be filed in writing within 60 days from receipt of the reconsideration decision. Enrollment appeals under Part 498 are heard by ALJs of the Departmental Appeals Board's Civil Remedies Division, not by the Office of Medicare Hearings and Appeals that hears claim appeals.

• Departmental Appeals Board review. A party dissatisfied with the ALJ decision may request review by the Appellate Division of the Departmental Appeals Board.

• Judicial review. After exhausting administrative remedies, a provider may seek judicial review in federal court under Sections 1866(h)(1) and (j)(8) of the Social Security Act.

Preclusion List Considerations

A revocation with an active re-enrollment bar may lead CMS to add the provider to the preclusion list if CMS determines that the underlying conduct is detrimental to the best interests of the Medicare program. CMS model letters explain that providers may request reconsideration of preclusion list placement within 60 calendar days and that the preclusion becomes effective 90 days after the 60-day period expires if no timely request is made. Under 42 CFR 498.5(n), if a provider receives contemporaneous notice of both a revocation and preclusion list placement, it may request a joint reconsideration of both actions and may not file separate requests.

How to Appeal Before It Is Too Late: A Step-by-Step Plan

Step 1: Read the Notice and Calculate Deadlines Immediately

• Note the date on the notice and the date received.

• Identify the regulatory basis for revocation, the effective date, the length of the re-enrollment bar, and any preclusion list action.

• Calculate the 30-day CAP deadline, if a CAP is available, and the 60-day reconsideration deadline.

• Note where each request must be filed.

Step 2: Engage Experienced Counsel

Revocation appeals involve technical regulations and strict procedures. Counsel experienced in Medicare enrollment appeals can evaluate the strongest arguments and help avoid procedural mistakes.

Step 3: Determine Whether to File a CAP, Reconsideration, or Both

• If the revocation is based on noncompliance under 424.535(a)(1) and the issue can be fixed, a CAP may restore enrollment more quickly.

• If the revocation was based on an error of fact or law, a reconsideration request is necessary to preserve appeal rights.

• Remember that a CAP denial is not appealable, while reconsideration preserves further appeal rights.

Step 4: Gather Evidence

Depending on the basis for revocation, evidence may include:

• Proof that the practice location was operational, such as photographs, leases, staffing schedules, signage, patient appointment records, and utility bills.

• Documentation showing that enrollment information was accurate or that changes were timely reported.

• Medical records, orders, and documentation supporting claims at issue in an abuse of billing privileges revocation.

• Evidence related to any conviction, licensing action, or exclusion, including court records and licensing board documents.

• Evidence of corrective actions taken.

• Statements from staff or other witnesses, where appropriate.

Step 5: Write a Complete, Well-Organized Reconsideration Request

• Identify each finding you dispute and explain why it is wrong.

• Cite the applicable regulations.

• Attach and reference all supporting evidence.

• Make sure the request is signed by an authorized person.

• Submit it to the correct address using a trackable method, and keep proof of delivery.

Step 6: Address Related Actions

• Evaluate whether other enrollments may be affected.

• Respond to any preclusion list notice within the required timeframe, using a joint reconsideration request if applicable.

• Review state Medicaid notices and appeal rights.

• Notify Medicare Advantage plans and other payers as required by contracts.

Step 7: Plan for Operational Impact

• Prepare for the loss of Medicare revenue after the effective date.

• Consider patient transitions and continuity of care.

• Communicate carefully with staff.

• Avoid billing Medicare for services furnished after the effective date unless and until enrollment is reinstated.

Step 8: Track the Appeal

• Calendar the expected reconsideration decision date.

• If the decision is unfavorable, calendar the 60-day ALJ deadline immediately.

Common Mistakes in Revocation Appeals

Providers sometimes lose appeal rights or weaken their position through avoidable mistakes:

• Missing the deadline. Treating the revocation notice as routine correspondence and filing after the 30-day CAP window or the 60-day reconsideration window.

• Filing only a CAP when the revocation is wrong. Because a CAP denial cannot be appealed, relying solely on a CAP can leave a provider without further recourse if the CAP is rejected.

• Submitting a thin reconsideration request. Filing a brief request without evidence, expecting to supplement it later, even though the reconsideration request is generally the only opportunity to submit information in the administrative process.

• Sending the request to the wrong place. Some revocations are reconsidered by the MAC and others by CMS's Provider Enrollment and Oversight Group. The notice specifies where to file.

• Unsigned or improperly signed requests. The request must be signed by the individual provider or an authorized or delegated official.

• Arguing the length of the bar instead of the revocation. Because the duration of the bar is generally not appealable, arguments should focus on whether the revocation itself was correct.

• Ignoring related notices. Failing to respond to a preclusion list notice or a Medicaid termination notice on time.

• Continuing to bill Medicare. Submitting claims for services after the revocation effective date can create overpayments and additional problems.

• Making unsupported statements. Every factual statement in an appeal should be accurate and supported by evidence.

How to Reduce the Risk of Revocation

• Keep enrollment information accurate and report changes on time under 42 CFR 424.516.

• Make sure practice locations are operational, staffed during posted hours, and match enrollment records, so that site visits do not result in non-operational findings.

• Screen owners, managing employees, and staff against exclusion lists.

• Report adverse legal actions as required.

• Respond promptly to revalidation requests and documentation requests.

• Monitor claim denial patterns, since a pattern of claims that fail to meet Medicare requirements can support an abuse of billing privileges revocation.

• Maintain an effective compliance program consistent with HHS-OIG's General Compliance Program Guidance.

Frequently Asked Questions

How long do I have to appeal a Medicare revocation?

Generally, a reconsideration request must be filed within 60 days from receipt of the notice, with receipt presumed to be five days after the date on the notice. A CAP, when available, must be submitted within 30 days of the notice's postmark date.

Can I appeal the length of my re-enrollment bar?

The Departmental Appeals Board has held that the duration of a re-enrollment bar is not an appealable initial determination. Providers can, however, appeal the revocation itself.

Can I submit evidence later in the appeal?

CMS notices state that the reconsideration request is the only opportunity to submit information during the administrative appeals process, unless an ALJ specifically allows otherwise. Submit all evidence with the reconsideration request.

What is the difference between a CAP and reconsideration?

A CAP shows that you have corrected the deficiency and is available only for certain revocations. Reconsideration argues that the revocation was wrong when it was made. A CAP denial is not appealable, while reconsideration preserves further appeal rights.

Will a Medicare revocation affect my Medicaid enrollment?

It may. State Medicaid agencies must terminate providers terminated by Medicare under 42 CFR 455.416, subject to the regulation's terms.

Conclusion

Medicare billing privilege revocation can end a provider's participation in Medicare for years, affect Medicaid and Medicare Advantage participation, and create lasting financial consequences. The appeal process offers real opportunities to challenge a revocation, but only if providers act quickly and correctly. The 30-day CAP window, the 60-day reconsideration deadline, and the rule that evidence must be submitted with the reconsideration request make early action essential.

Providers can protect themselves by reading revocation notices immediately, engaging experienced counsel, choosing the right appeal path, submitting complete evidence on time, addressing related actions such as preclusion and Medicaid termination, and, over the long term, maintaining accurate enrollment information and strong compliance practices.

How HealthBridge Can Help

HealthBridge is a healthcare management consulting firm that specializes in Medicare enrollment, program integrity, and compliance. We help providers review revocation notices, organize supporting documentation, support corrective action plans and reconsideration requests in coordination with legal counsel, and strengthen enrollment and compliance practices to reduce future risk. If your organization has received a revocation notice or wants to reduce its risk, please get in touch with us. We will be happy to help you with this topic.

References

• Electronic Code of Federal Regulations. 42 CFR 424.535, Revocation of Enrollment in the Medicare Program. https://www.ecfr.gov/current/title-42/section-424.535

• Electronic Code of Federal Regulations. 42 CFR 424.530, Denial of Enrollment in the Medicare Program. https://www.ecfr.gov/current/title-42/section-424.530

• Electronic Code of Federal Regulations. 42 CFR 424.540, Deactivation of Medicare Billing Privileges. https://www.ecfr.gov/current/title-42/section-424.540

• Electronic Code of Federal Regulations. 42 CFR 424.545, Provider and Supplier Appeals of the Denial or Revocation of Medicare Billing Privileges. https://www.ecfr.gov/current/title-42/section-424.545

• Electronic Code of Federal Regulations. 42 CFR 405.803, Appeals of Provider and Supplier Enrollment Determinations. https://www.ecfr.gov/current/title-42/section-405.803

• Electronic Code of Federal Regulations. 42 CFR Part 498, Appeals Procedures for Determinations That Affect Participation in the Medicare Program. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-498

• Electronic Code of Federal Regulations. 42 CFR 455.416, Termination or Denial of Enrollment. https://www.ecfr.gov/current/title-42/section-455.416

• Electronic Code of Federal Regulations. 42 CFR 424.516, Additional Provider and Supplier Requirements for Enrolling and Maintaining Active Enrollment Status. https://www.ecfr.gov/current/title-42/section-424.516

• Centers for Medicare & Medicaid Services. Maintaining Compliance with Enrollment Requirements and the Appeals Process. https://www.cms.gov/medicare/provider-enrollment-and-certification/medicareprovidersupenroll/downloads/maintaining_compliance_with_enrollment_requirements.pdf

• Centers for Medicare & Medicaid Services. CMS Manual System, Pub. 100-08 Medicare Program Integrity, Transmittal 659. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R659PI.pdf

• Centers for Medicare & Medicaid Services. CMS Manual System, Pub. 100-08 Medicare Program Integrity, Transmittal 609. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R609PI.pdf

• Centers for Medicare & Medicaid Services. Preclusion List Model Letter, Revoked with Active Enrollment Bar. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Downloads/Preclusion_List_Model_Letter-Revoked_With_Active_Enrollment_Bar.pdf

• U.S. Department of Health and Human Services, Departmental Appeals Board. Revive Spine and Pain Center, DAB CR6980 (2026). https://www.hhs.gov/about/agencies/dab/decisions/alj-decisions/2026/alj-cr6980/index.html

• U.S. Department of Health and Human Services, Departmental Appeals Board. Celia R. Zuniga, DAB CR6478 (2024). https://www.hhs.gov/about/agencies/dab/decisions/alj-decisions/2024/alj-cr6478/index.html

• U.S. Department of Health and Human Services, Departmental Appeals Board. Group Health Plan, Inc. d/b/a HealthPartners Specialty Center 401, DAB CR6523 (2024). https://www.hhs.gov/about/agencies/dab/decisions/alj-decisions/2024/alj-cr6523/index.html

• Federal Register. Calendar Year 2027 Home Health Prospective Payment System Rate Update; Medicare Provider Enrollment and DMEPOS Policies, Proposed Rule (July 6, 2026). https://www.federalregister.gov/documents/2026/07/06/2026-13602/calendar-year-2027-home-health-prospective-payment-system-hh-pps-rate-update-requirements-for-the-hh

• Centers for Medicare & Medicaid Services, Center for Program Integrity. Crushing Fraud: Annual Report 2025. https://www.cms.gov/files/document/crushing-fraud-annual-report.pdf

• U.S. Department of Justice, Office of Public Affairs. National Health Care Fraud Takedown Results in 455 Defendants Charged in Connection with Over $6.5 Billion in Alleged Fraud (June 23, 2026). https://www.justice.gov/opa/pr/national-health-care-fraud-takedown-results-455-defendants-charged-connection-over-65

• U.S. Department of Health and Human Services, Office of Inspector General. General Compliance Program Guidance. https://oig.hhs.gov/compliance/general-compliance-program-guidance/