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New Preclusion List Policy - Chapter 16, 2019 UnitedHealthcare Administrative Guide

New Preclusion List Policy

The Centers for Medicare and Medicaid Services (CMS) has a Preclusion List effective for claims with dates of service on or after January 1, 2019. The Preclusion List applies to both Medicare Advantage plans as well as Part D plans.

The Preclusion is comprised of a list of prescribers and individuals or entities who:

  • Are revoked from Medicare, are 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; or
  • Have engaged in behavior for which CMS could have revoked the prescriber, individual or entity to the extent possible if they had been enrolled in Medicare and that the underlying conduct that would have led to the revocation is detrimental to the best interests of the Medicare program.

Care providers receive notification from CMS of their placement on the Preclusion List, via letter, and will have the opportunity to appeal with CMS before the preclusion is effective. There is no opportunity to appeal with UnitedHealthcare.

Once the preclusion date is effective, claims will no longer be paid, pharmacy claims will be rejected, and the provider will be terminated from the UnitedHealthcare network if they are contracted until such time the provider is removed from the preclusion status.

As contracted providers of UnitedHealthcare, you must ensure that payments for healthcare services or items are not made to individuals or entities on the Preclusion List, including employed or contracted individuals or entities.

For more information on the Preclusion List, visit cms.com.