The CMS Preclusion List and You

What is the CMS Preclusion List?

The Preclusion List is a list of prescribers and individuals or entities who fall within any of

the following categories:

(1) Are currently 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

(2) Have engaged in behavior for which CMS could have revoked the prescriber, individual or entity to the extent applicable if they had been enrolled in Medicare, and CMS determines that the underlying conduct that would have led to the revocation is detrimental to the best interests of the Medicare program. Such conduct includes, but are not limited to, felony convictions and Office of Inspector General (OIG) exclusions.

Why was it created? 

The CMS-4182 Final Rule was created to make revisions to the Medicare Advantage (MA) program (Part C) and Prescription Drug Benefit Program (Part D) regulations based on our continued experience in the administration of the Part C and Part D programs and to implement certain provisions of the Comprehensive Addiction and Recovery Act and the 21st Century Cures Act.

Will I get access to it?

Did you have access to the Medicare Advantage (MA) program (Part C) and/or Prescription Drug Benefit Program (Part D) in the past? If so, then you can get access to this list by applying to receive access to the EDMI through CMS. Submit your application here

Who is required to search the CMS Preclusion List?

Preclusion List Requirements for Prescribers in Part D and Individuals and Entities in MA, Cost Plans, and PACE

This final rule will rescind current regulatory provisions that require prescribers of Part D drugs and providers of MA services and items to enroll in Medicare in order for the Part D drug or MA service or item to be covered. As a replacement, a Part D plan sponsor will be required to reject, or require its pharmacy benefit manager to reject, a pharmacy claim for a Part D drug if the individual who prescribed the drug is included on the ‘‘preclusion list.’’ Similarly, an MA service or item will not be covered if the provider that furnished the service or item is on the preclusion list. The preclusion list will consist of certain individuals and entities that are currently revoked from the Medicare program under 42 CFR 424.535 and are under an active reenrollment bar, or have engaged in behavior for which CMS could have revoked the individual or entity to the extent applicable if they had been enrolled in Medicare, and CMS determines that the underlying conduct that led, or would have led, to the revocation is detrimental to the best interests of the Medicare program. We believe that this change from an enrollment requirement to a preclusion list requirement will reduce the burden on Part D prescribers and MA providers without compromising our program integrity efforts.

Where can I get more information?

The CMS Preclusion List Homepage

Erin’s two cents:

The CMS preclusion list is not for background screening. It’s available to Part C and Part D prescribers. Its primary purpose is to eliminate the opioid epidemic. The creation of this new list is in response to the Comprehensive Addiction and Recovery Act of 2016 (CARA). There may be excluded providers on this list, however, those exclusions will also still be listed on the OIG. 


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