Victoria Ridgeway, DAB CR6567 (2024)

DECISION

Petitioner, Victoria Ridgeway, is a nurse practitioner, practicing in Alabama, who applied to participate in the Medicare program as a supplier of services.  The Centers for Medicare & Medicaid Services (CMS) has granted her application, with a “reassignment effective date” of March 30, 2024.1  Petitioner now asks for an earlier effective date. 

Because she filed her subsequently-approved Medicare application on April 29, 2024, I find that April 29 is the correct effective date for Petitioner’s enrollment.  I may not review CMS’s retrospective billing determination. 

Background

In a notice letter, dated May 15, 2024, the Medicare contractor, Palmetto GBA, advised Petitioner Ridgeway (and her medical practice) that it approved her Medicare enrollment 

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and reassignment applications, effective March 30, 2024.  CMS Ex. 5.  Petitioner requested reconsideration, asking for a billing date of August 1, 2023.  CMS Exs. 2, 4.  

In a reconsidered determination, dated June 25, 2024, the contractor affirmed the initial determination.  CMS Ex. 1.  Petitioner appealed, and the matter is now before me. 

Because neither party proposes any witnesses, an in-person hearing would serve no purpose.  See Acknowledgment and Prehearing Order at 4, 5 (¶¶ 4(c)(iv), 8) (August 2, 2024)).  I may therefore decide this case based on the written record, without considering whether the standards for summary judgment are satisfied.  See Anil Hanuman, D.O., DAB No. 3080 at 12 (2022). 

CMS submits its motion and brief (CMS Br.) with 15 exhibits (CMS Exs. 1-15).  Although directed to do so, Petitioner declined to file a brief or any other documents.  Acknowledgment at 3 (¶ 4(b)).  In the absence of a brief, I consider the arguments set forth in her hearing request.  (E-File #1); see Hanuman, DAB No. 3080 at 12.2

In the absence of any objections, I admit into evidence CMS Exs. 1-15.  See Acknowledgment at 5 (¶ 7). 

Discussion

1. On April 29, 2024, Petitioner filed her subsequently-approved enrollment application, and April 29, 2024 is therefore the effective date of her Medicare enrollment. 42 C.F.R. § 424.520(d).3

Enrollment.  Petitioner Ridgeway 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.  Act § 1834(j)(1)(A); 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.  

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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. § 424.502.4  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 a non‑physician practitioner, 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). 

If a non-physician practitioner meets all program requirements, CMS may allow her to bill retrospectively for up to 30 days prior to the effective date “if circumstances precluded enrollment in advance of providing services to Medicare beneficiaries.”  42 C.F.R. § 424.521(a)(1).  Under other circumstances, CMS may allow her to bill retrospectively for up to 90 days.  42 C.F.R. § 424.521(a)(2).  I have no authority to review CMS’s determinations regarding retrospective billing.  See 42 C.F.R. § 498.3(b). 

Petitioner’s enrollment.  Here, on April 29, 2024, Petitioner filed, via the PECOS system, her Medicare enrollment application (CMS-855I), which the contractor subsequently approved.  CMS Ex. 11.5  Thus, pursuant to section 424.520(d), the date Petitioner filed her subsequently-approved enrollment application – April 29, 2024 – is the correct effective date.  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). 

Pursuant to its authority under section 424.521(a)(1), CMS has allowed Petitioner to bill 30-days retrospectively, so her effective billing date is March 30, 2024. 

The rejected application.  Petitioner points out that she submitted her “initial application” on March 30, 2023.  She concedes that some issues were not resolved “that resulted in her application being sent back for correction.”  She maintains that “the corrections were sent,” but the application was nevertheless denied.  Hearing Request (E-

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File # 1).  She provides no evidence as to when (or if) she submitted the missing document. 

The documents submitted here confirm that, on March 30, 2023, petitioner submitted, via PECOS, an enrollment application (CMS Ex. 15) and an application to reassign her benefits to her medical practice.  CMS Ex. 14.  In a notice dated April 12, 2023, the Medicare contractor acknowledged receiving the application and directed Petitioner to submit, within 30 calendar days, the required nurse practitioner certification.  The notice warned that “[w]e may reject your application(s) if you do not furnish complete information within 30 calendar days from the postmarked date of this letter . . . .”  CMS Ex. 12. 

In a notice dated May 16, 2023, the contractor advised Petitioner that it was rejecting her applications because it had not received her nurse practitioner board certification.  CMS Ex. 10.  I have no authority to review a rejected application.  42 C.F.R. § 424.525(d); see Timothy Ekhlassi, M.D., M.P.H., DAB No. 3065 at 2 (2022); James Shepard, M.D., DAB No. 2793 at 8 (2017).  Nor may I grant Petitioner an earlier effective date based on any equitable or policy arguments.  Sokoloff, DAB No. 2972 at 9. 

Conclusion

Because Petitioner filed her subsequently-approved Medicare application on April 29, 2024, April 29, 2024 is her effective date of enrollment.