Jan 1, 2020

  • Applicable to all states except NC

Applicable to all states e...
Skip left navigation

Preclusion List Policy- Chapter 16, 2020 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 April 1, 2019. The Preclusion List applies to both MA plans as well as Part D plans.

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

  • Are revoked from Medicare, are under an active re-enrollment 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; or
  • Have been convicted of a felony under federal or state law within the previous 10 years and that CMS deems detrimental to the best interests of the Medicare program.

Care providers receive a letter from CMS notifying them of their placement on the Preclusion List. They have the opportunity to appeal with CMS before the preclusion is effective. There is no opportunity to appeal with UnitedHealthcare. CMS updates the Preclusion List monthly and notifies MA and Part D plans of the claim- rejection date, the date upon which we reject or deny a care provider’s claims due to precluded status. Once the claim-rejection date is effective, a precluded care provider’s claims will no longer be paid, pharmacy claims will be rejected, and the care provider will be terminated from the UnitedHealthcare network. Additionally, the precluded care provider must hold Medicare beneficiaries harmless from financial liability for services provided on or after the claim- rejection date.

As contracted care providers of UnitedHealthcare, you must ensure that payments for health care 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.gov