Blue Cross will start notifying providers on the CMS preclusion list in January

The Centers for Medicare & Medicaid Services adopted a rule in April 2018 that stipulates providers can’t be on a preclusion list and receive payment from a Medicare plan. CMS will make the preclusion list available to Part D sponsors and Medicare Advantage plans, beginning Jan. 1, 2019.

Once Blue Cross Blue Shield of Michigan receives the preclusion list on the first of each month, our Provider Enrollment and Data Management department will send a letter — within 30 days — to any contracted Medicare Plus Blue^SM PPO provider who is on the list. The letter will include the effective date of the provider’s preclusion, which will be 90 days from the date of the published preclusion list.

We’re required to remove any contracted provider who is included on the preclusion list from our networks. We’re also required to notify enrollees who have received care in the last 12 months from a contracted provider or a prescription from a provider who is on the preclusion list.

In addition, effective April 1, 2019:

• 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.
• Medicare Advantage plans will be required to deny payment for a health care item or service given by an individual or entity on the preclusion list.

What is the preclusion list?

The preclusion list is a list of providers and prescribers who are precluded from receiving payment for Medicare Advantage items and services or Part D drugs furnished or prescribed to Medicare beneficiaries. The list was created to replace the Medicare Advantage and prescriber enrollment requirements and to ensure patient protections and to protect the trust funds from prescribers and providers identified as bad actors.

More information is available at the CMS website.**

** Blue Cross Blue Shield of Michigan doesn’t own or control this website.