Nume TMS Clinics, PLLC, DAB CR6662 (2025)

DECISION

Petitioner, Nume TMS Clinics, PLLC, is a clinic, located in Boise, Idaho, that provides transcranial magnetic stimulation (TMS).1  After the Medicare contractor deactivated its Medicare billing privileges, Petitioner submitted a new application, seeking to reactivate its enrollment.  Acting on behalf of the Centers for Medicare & Medicaid Services (CMS), the contractor approved the application, with an effective billing date of July 30, 2024.  As a result, Petitioner’s billing privileges lapsed from June 1 through July 29, 2024. 

Petitioner asks that its billing privileges be reinstated, effective June 1, 2024. 

Because Petitioner filed its subsequently-approved reactivation application on July 30, 2024, July 30 is the earliest possible effective date for its Medicare reactivation.  See 42 C.F.R. § 424.540(d)(2). 

I have no authority to review the deactivation nor to order retrospective reimbursement for services provided during the period of deactivation.  

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Background

The Medicare contractor, Noridian Healthcare Solutions, has approved Petitioner’s reactivation enrollment application with an effective date of July 30, 2024.  CMS Ex. 12.  Petitioner requested reconsideration.  CMS Exs. 14, 15.  In a reconsidered determination, dated November 14, 2024, a contractor hearing officer affirmed the July 30, 2024 effective date.  CMS Ex. 16. 

Petitioner appealed and the matter has recently been reassigned to me. 

CMS moves for summary judgment.  However, because neither party proposes any witnesses, an in-person hearing would serve no purpose.  See Standing Pre-Hearing Order at 5, 9, 10 (¶¶ 8(d)(iv), 12, 13, 14) (December 31, 2024).  I may therefore decide this case based on the written record, without considering whether the standards for summary judgment are satisfied. 

CMS submits its motion and brief (CMS Br.) with 18 exhibits (CMS Exs. 1-18).  In the absence of any objections, I admit into evidence CMS Exhibits 1-18.  See Standing Order at 9 (¶ 11).  Petitioner submitted a response (P. Br.).  

Discussion

1. 1. On July 30, 2024, Petitioner filed its subsequently-approved Medicare reactivation application, and the effective date of its reactivation can be no earlier than that date. 42 C.F.R. § 424.540(d)(2).2

Enrollment.  Petitioner Nume TMS Clinics, PLLC participates in the Medicare program as a “supplier” of services.  CMS Ex. 17 at 8; see Social Security Act § 1861(d); 42 C.F.R. §§ 400.202, 498.2.  To receive Medicare payments for the services furnished to program beneficiaries, a 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 privilege.  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. § 424.502.3  When CMS determines that a prospective supplier meets the applicable enrollment requirements, it grants Medicare 

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billing privileges, which means that the supplier can submit claims and receive payments from Medicare for covered services provided to program beneficiaries.  For physician and non-physician practitioner organizations submitting a new enrollment application, 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).  However, because this case involves re-enrollment after a deactivation, additional regulations apply. 

Deactivation and reactivation.  To maintain its billing privileges, a supplier must report a change in practice location within 30 days.  42 C.F.R. § 424.516(d)(1); other changes must be reported within 90 days.  42 C.F.R. § 424.516(d)(2).  If the supplier does not report changes to the information that it previously supplied on its enrollment application, CMS may deactivate its Medicare billing privileges.  42 C.F.R. § 424.540(a)(2). 

To maintain its billing privileges, a supplier must also resubmit and recertify the accuracy of its enrollment information every five years.  42 C.F.R. § 424.515.  CMS may perform off-cycle revalidations at any time.  42 C.F.R. § 424.515(d).  Within 60 days of receiving CMS’s notice, the supplier must submit the applicable enrollment application and supporting documentation.  42 C.F.R. § 424.515(a)(2).  CMS may deactivate a supplier’s billing privileges if the supplier does not furnish complete and accurate information and all supporting documentation within 90 calendar days of receiving CMS’s request that it do so.  42 C.F.R. § 424.540(a)(3); see 42 C.F.R. § 424.540(a)(2) (authorizing deactivation if the supplier fails to report a change of information within 90 days of the time a change occurred). 

The regulations governing re-enrollment after a deactivation differ in significant ways from the enrollment regulations.  See 86 Fed. Reg. 62,240, 62,359-60 (Nov. 9, 2021). To reactivate its billing privileges, the supplier must recertify that its enrollment information currently on file with Medicare is correct, furnish any missing information, as appropriate, and comply with all applicable enrollment requirements.  42 C.F.R. § 424.540(b)(1).  CMS may also require that a deactivated supplier submit a complete enrollment application.  42 C.F.R. § 424.540(b)(2).  The effective date of reactivation of billing privileges is the date on which the Medicare contractor received the supplier’s submissions that were processed to approval.  42 C.F.R. § 424.540(d)(2). 

Here, in 2017, Petitioner enrolled in the Medicare program, listing its business name as Treasure Valley TMS, PLLC, and its mailing address and practice location as 413 N. Allumbaugh St., Ste. 101, Boise, Idaho.  CMS Ex. 17 at 1-3.  On February 8, 2024, Petitioner submitted, to the Medicare contractor, an enrollment application advising of changes in its Medicare information:  its business name changed to Nume TMS Clinics, PLLC; its practice location and correspondence address changed to 5561 N. Glenwood St., Ste. B, Garden City, Idaho.  CMS Ex. 2 at 1-3.  However, the application listed the N. Allumbaugh St. address as the address of its contact person.  CMS Ex. 2 at 7. 

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In a letter dated February 26, 2024, the contractor acknowledged receiving the February 8 application but directed Petitioner to submit additional information.  The letter cautioned that the contractor might reject the application if Petitioner did not furnish complete information within 30 calendar days from the postmarked/emailed date of the letter.  CMS Ex. 3; see 42 C.F.R. § 424.525. 

Petitioner did not respond within 30 days. 

In a letter dated March 29, 2024, the contractor advised Petitioner that it was rejecting the application because the application was incomplete, and Petitioner had not provided the requested additional information within 30 days.  The letter also advised Petitioner that it could complete a new enrollment application.  The contractor sent the letter to the correspondence address Petitioner listed in the February 8 application (5561 N. Glenwood St.).  CMS Ex. 4. 

In the meantime, in a letter dated February 21, 2024, the contractor directed Petitioner to revalidate its Medicare enrollment no later than May 31, 2024.  The letter warned that the contractor might stop Petitioner’s billing privileges if it didn’t receive a timely response.  Petitioner would not be paid for services rendered during the period of deactivation.  CMS Ex. 1.  Because Petitioner had not successfully updated its information, the contractor sent the letter to Treasure Valley TMS, PLLC at the Allumbaugh address (which nevertheless was one of the addresses listed for the Petitioner’s contact person).  

Petitioner did not respond. 

In a letter dated June 5, 2024, the contractor advised Petitioner that, because it had not timely responded to the revalidation request, the contractor was placing a stay on Petitioner’s enrollment record, effective June 5, 2024, pursuant to 42 C.F.R. § 424.541.  Although Petitioner would remain enrolled in the Medicare program, the contractor would reject any claims submitted for services or items that Petitioner furnished.  CMS Ex. 6 at 1.  Again, the contractor sent the letter to Treasure Valley TMS, PLLC at the Allumbaugh address.  The letter was returned to the contractor.  CMS Ex. 6 at 7. 

On July 30, 2024, the Medicare contractor received Petitioner’s Medicare application, which, after some back-and-forth (so that the application would be complete), the contractor processed to approval.  CMS Exs. 7, 12.  July 30, 2024 is therefore the effective date for reactivating Petitioner’s billing privileges.  See 42 C.F.R. § 424.540(d)(2). 

Petitioner acknowledges that it failed to update essential contact information and made other errors, which led to the deactivation.  Nevertheless, Petitioner claims that it was not aware of the revalidation deadline and that it relies on the Medicare program to provide critical service to Idaho residents.  P. Br. 

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I have no authority to review a deactivation or grant Petitioner an earlier effective date based on any equitable or policy arguments.  Howard M. Sokoloff, DPM, MS, Inc., DAB No. 2972 at 6, 9 (2019); Wishon Radiological Med. Grp., Inc., DAB No. 2941 at 6-7 (2019); Ark. Health Grp., DAB No. 2929 at 7-9 (2019); James Shepard, M.D., DAB No. 2793 at 8 (2017).  

Nor may I direct the contractor to allow retrospective reimbursement.  A supplier may not receive payment for services or items furnished while deactivated.  42 C.F.R. §§ 424.540(e), 424.555(b).  This represents a departure; CMS previously permitted retrospective billing after reactivation.  In promulgating the new regulation, the Secretary explained the change: 

• After careful reflection . . . the most sensible approach from a program integrity perspective is to prohibit such payments altogether.  In our view, a provider or supplier should not be effectively rewarded for its non-adherence to enrollment requirements (for example, failing to respond to a revalidation request or failing to timely report enrollment information changes) by receiving payment for services or items furnished while out of compliance. 

86 Fed. Reg. 62,240, 62,359-60 (Nov. 9, 2021); see Michael B. Zafrani, M.D., DAB No. 3075 at 2 n.1 (2022). 

Conclusion

Because Petitioner filed its subsequently-approved reactivation application on July 30, 2024, July 30 is the earliest possible effective date.  See 42 C.F.R. § 424.540(d)(2).  

I may not review the deactivation. 

Retrospective reimbursement is not available for those whose enrollment has been deactivated.  42 C.F.R. § 424.540(e).