Department of Health and Human Services
DEPARTMENTAL APPEALS BOARD
Civil Remedies Division
Elite Care Ambulance, Inc. d/b/a Care Plus Medical Services,
Centers for Medicare & Medicaid Services.
Docket No. C-19-299
Decision No. CR5817
Petitioner, Elite Care Ambulance, Inc., is a non-emergency medical services transportation company, operating in New Jersey, that participates in the Medicare program as a supplier of services. Its Medicare billing privileges were deactivated, and the company subsequently re-enrolled in the program. The Centers for Medicare & Medicaid Services (CMS) granted its revalidation application, effective June 25, 2018, which resulted in a 17-day billing gap (June 8-24, 2018).
Because Petitioner filed its subsequently-approved application on June 25, 2018, I find that June 25 is the correct effective date for its revalidation. I have no authority to review the deactivation.
In a notice letter dated June 29, 2018, the Medicare contractor, Novitas Solutions, advised Petitioner that it approved the supplier’s revalidated Medicare enrollment. However, because the supplier had not responded to the contractor’s development request, there would be a gap in billing privileges from June 8 through 24, 2018. CMS Ex. 7.
Petitioner requested reconsideration. CMS Ex. 8. In its request, Petitioner asked that the billing gap be eliminated. Petitioner maintained that it received only one development letter, to which it timely responded with all the information requested, and that the contractor’s representative “confirmed” that all documents had been received. When Petitioner received its deactivation notice, it learned, for the first time, that the contractor had not received the required attachments to its response. Petitioner had no record that the contractor sent any follow-up requests for the documents. CMS Ex. 8 at 3.
In a reconsidered determination, dated November 5, 2018, the contractor denied Petitioner’s request and determined that the lapse in coverage would remain. CMS Ex. 11. Petitioner appealed.
CMS moves for summary judgment. My initial order instructs the parties to list any proposed witnesses and to submit their written direct testimony. Acknowledgment and Prehearing Order at 3, 5 (¶¶ 4(c)(iv), 8) (January 8, 2019). The order also directs the parties to indicate which, if any, of the opposing side’s witnesses the party wishes to cross-examine and explains that an in-person hearing is needed only if a party wishes to cross-examine the opposing side’s witnesses. Id. at 5-6 (¶¶ 9, 10). CMS lists no witnesses. Petitioner lists one witness and provides a written declaration, but CMS has not asked to cross-examine him. See id. at 5 (¶ 9). An in-person hearing would therefore serve no purpose, and I may decide this case based on the written record without considering whether the standards for summary judgment are met.
CMS submits its motion and brief (CMS Br.) with 11 exhibits (CMS Exs. 1-11). Petitioner submits a response (P. Br.) with one exhibit (P. Ex. 1). In the absence of any objections, I admit into evidence CMS Exs. 1-11 and P. Ex. 1. See Acknowledgment and Pre-hearing Order at 5 (¶ 7).
On June 25, 2018, Petitioner filed its subsequently-approved revalidation application, and the effective date can be no earlier than that date. 42 C.F.R. § 424.520(d).1
Enrollment. Petitioner participates in the Medicare program as a “supplier” of services. Social Security Act § 1861(d); 42 C.F.R. § 498.2. To receive Medicare payments for the services furnished to program beneficiaries, a prospective supplier must enroll in the program. 42 C.F.R. § 424.505. “Enrollment” is the process by which CMS and its
contractors: 1) identify the prospective supplier; 2) validate the supplier’s eligibility to provide items or services to Medicare beneficiaries; 3) identify and confirm a supplier’s owners and practice location; and 4) grant the supplier Medicare billing privileges. 42 C.F.R. § 424.502.
To enroll, a prospective supplier must complete and submit an enrollment application. 42 C.F.R. §§ 424.510(d)(1), 424.515(a). An enrollment application is either a CMS-approved paper application or an electronic process approved by the Office of Management and Budget. 42 C.F.R. § 424.502.2 When CMS determines that a prospective supplier meets the applicable enrollment requirements, it grants Medicare billing privileges, which means that the supplier can submit claims and receive payments from Medicare for covered services provided to program beneficiaries. For an ambulance supplier, the effective date for billing privileges “is the later of the date of filing” a subsequently-approved enrollment application or “the date that the supplier first began furnishing services at a new practice location.” 42 C.F.R. § 424.520(d) (emphasis added).
Revalidation and deactivation. To maintain its billing privileges, a supplier must, at least every five years, resubmit and recertify the accuracy of its enrollment information, a process referred to as “revalidation.” 42 C.F.R. § 424.515. In addition to periodic revalidations, CMS may, at other times and for its own reasons, ask a supplier to recertify the accuracy of its enrollment information. 42 C.F.R. § 424.515(d)-(e). Within 60 days of receiving CMS’s notice to recertify, the supplier must submit an appropriate enrollment application with complete and accurate information and supporting documentation. 42 C.F.R. § 424.515(a)(2).
If, within 90 days from receipt of CMS’s notice, the supplier does not furnish complete and accurate information and all supporting documentation or does not resubmit and certify the accuracy of its enrollment information, CMS may deactivate its billing privileges, and no Medicare payments will be made. 42 C.F.R. §§ 424.540(a)(3), 424.555(b). To reactivate its billing privileges, the supplier must complete and submit a new enrollment application. 42 C.F.R. §424.540(b)(1). It is settled that, following deactivation, section 424.520(d) governs the effective date of reenrollment. Howard M. Sokoloff, DPM, MS, Inc., DAB No. 2972 (2019); Urology Grp. of NJ, LLC, DAB No. 2860 (2018); Willie Goffney, Jr., M.D., DAB No. 2763 at 7 (2017), aff’d sub nom. Goffney v. Azar, No. CV 17-8032 MRW (C.D. Cal. Sept. 25, 2019).
I have no authority to review a deactivation. Sokoloff, DAB No. 2972 at 6; Ark. Health Grp., DAB No. 2929 at 7-9 (2019).
Petitioner’s deactivation and reenrollment. Here, in notice letters, dated October 12, 2017, the contractor advised Petitioner to revalidate its Medicare enrollment by updating or confirming all of the information in its record. The letters direct Petitioner to revalidate, no later than December 31, 2017, by updating the information through PECOS or by submitting the appropriate updated paper applications (Form CMS-855). The letters warned that failing to respond would result in a hold on payments and possible deactivation of Medicare enrollment. If deactivated, Petitioner would not be paid for services rendered during the period of deactivation. CMS Ex. 1.
Petitioner filed its enrollment application on February 22, 2018. CMS Ex. 2. However, the contractor determined that the application was incomplete. In a development letter, dated April 16, 2018, the contractor asked Petitioner to submit revisions and additional documentation, including information regarding each of its multiple vehicles. The letter warned that Petitioner’s application might be rejected if Petitioner did not furnish complete information within 30 calendar days from the letter’s postmarked date. CMS Ex. 3.
Petitioner responded on May 14, 2018. CMS Ex. 4; P. Ex. 1 at 1. However, the contractor determined that its response was incomplete; it submitted vehicle information for just one of its eleven new vehicles. CMS Ex. 4.
In a notice, dated June 8, 2018, the contractor advised Petitioner that its billing privileges were stopped, effective that date, because it had not revalidated its enrollment record or had not responded to the contractor’s request for more information. The notice instructed Petitioner to revalidate its enrollment record through PECOS or to submit an updated paper enrollment application, CMS-855B. CMS Ex. 5.
On June 25, 2018, Petitioner filed a Medicare enrollment application (CMS-855B), which the contractor subsequently approved. CMS Ex. 6.3 Thus, pursuant to section 424.520(d), the date Petitioner filed its subsequently-approved enrollment application – June 25, 2018 – is the correct effective date of enrollment. Sokoloff, DAB No. 2972; Urology Grp., DAB No. 2860; Goffney, DAB No. 2763 at 7.
Petitioner, however, challenges the contractor’s assertion that it did not timely file all of the requested documentation. According to Petitioner, it responded, within 30 days, to the contractor’s April 16 development letter by submitting, via fax, all of the information requested. When it learned that the contractor had not received the fax, it sent a second
copy of the documents to the new fax number provided, again within the 30-day deadline. The contractor did not send an additional development letter so, until it received the deactivation notice, Petitioner was not aware that documents were missing. P. Br.
Whether or not Petitioner’s complaints have merit, I simply have no authority to review the deactivation. Sokoloff, DAB No. 2972 at 6; Ark. Health Grp., DAB No. 2929 at 7-9 (and cases cited therein).
Because Petitioner filed its subsequently-approved reactivation application on June 25, 2018, June 25 is the effective date for the reactivation of its Medicare billing privileges, with a 17-day coverage gap. I have no authority to review the deactivation.
Carolyn Cozad Hughes Administrative Law Judge
1. I make this one finding of fact/conclusion of law.
- back to note 1 2. CMS’s electronic process is referred to as PECOS (Provider Enrollment, Chain, and Ownership System).
- back to note 2 3. The application is date-stamped in the upper left corner. The first two letters of the stamp indicate the year (18); the next two indicate the month (06); and the next two indicate the day (25).
- back to note 3