Rosemarie Torio, DAB CR6763 (2025)

DECISION

Petitioner, Rosemarie Torio, is a physical therapist, practicing in California, who participates in the Medicare program as a supplier of services.  On February 18, 2025, she applied to reassign her Medicare benefits to Vertex Healthcare Solutions – Southern California (PTAN CB264376), a group practice.  The Medicare contractor, acting on behalf of the Centers for Medicare & Medicaid Services (CMS) has granted her application, with a “retrospective billing date” of December 20, 2024.  Petitioner now asks for an earlier date. 

Because she filed her subsequently-approved application on February 18, 2025, and a reassignment of benefits can be effective up to 30 days before the application to reassign benefits (Form 855R) is submitted, January 19, 2025 is the earliest effective date of reassignment.  December 20, 2024 is the earliest possible retrospective billing date. 

Background

In a notice letter, dated February 28, 2025, the Medicare contractor, Noridian Healthcare Solutions, advised Petitioner Torio that it approved her “Change of Information” application with a “reassignment effective date” of December 20, 2024.  CMS Ex. 7.  Petitioner requested reconsideration, asking that the date of reassignment be changed to September 16, 2024.  CMS Ex. 8.  In a reconsidered determination, dated June 6, 2025,

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the Medicare contractor concluded that December 20, 2024, is the earliest possible retrospective billing date and, after correcting the inaccurate designation (“reassignment effective date” vs. “retrospective billing date”), affirmed the initial determination.  CMS Ex. 2. 

Petitioner appealed, and the matter is now before me. 

Decision on the written record.  The parties have filed cross-motions for summary judgment.  However, because neither party proposes any witnesses, an in-person hearing would serve no purpose.  See Acknowledgment and Prehearing Order at 4, 5, 6 (¶¶ 4(c)(iv), 8, 10) (June 9, 2025).  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) (citations omitted). 

CMS submitted its motion and brief (CMS Br.) with eight exhibits (CMS Exs. 1-8).  In response, Petitioner submitted her own motion and brief (P. Br.) with no additional exhibits.  CMS submitted a reply to Petitioner’s motion.  In the absence of any objections, I admit into evidence CMS Exs. 1-8.  See Acknowledgment at 5 (¶ 7). 

Discussion

1. On February 18, 2025, Petitioner filed her subsequently-approved application to reassign benefits; the reassignment of benefits was effective 30 days earlier – on January 19, 2025 – and her earliest possible retrospective billing date was December 20, 2024.  42 C.F.R. §§ 424.522(a); 424.521(a)1

Enrollment.  Petitioner Torio 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.  

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

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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 a non-physician, 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). 

A supplier may reassign her billing privileges under certain circumstances, including where the reassignment is to an employer or to a Medicare-enrolled entity pursuant to a contractual arrangement under which the entity bills for the supplier’s services.  42 C.F.R. § 424.80(b) and (d). 

Petitioner’s enrollment.  Here, on February 18, 2025, Petitioner filed, via the PECOS system, her application to reassign her Medicare benefits (CMS-855R) to Vertex Healthcare Solutions – Southern California (PTAN CB264376), which the contractor subsequently approved.  CMS Exs. 4, 7.  Thus, pursuant to section 424.520(d), the date Petitioner filed her subsequently-approved enrollment application – February 18, 2025 – is the correct effective date of enrollment.  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 Goffney v. Azar, No. CV 17-8032 MRW (C.D. Cal. Sept. 25, 2019).  

Pursuant to section 424.522(a), the reassignment of Petitioner’s benefits is effective beginning 30 days before she submitted Form CMS-855R – in this case, on January 19, 2025.  A non-physician or non-physician organization may retrospectively bill for services for up to 30 days prior to the effective date, if CMS determines that certain circumstances are met.  42 C.F.R. § 424.521(a).  Thus, December 20, 2024 is Petitioner’s earliest possible retrospective billing date. 

Petitioner asks that her “effective date” (really, retrospective billing date) be adjusted retroactively to align with her enrollment status for Vertex Healthcare Solutions – Northern California (PTAN CA463110).  On November 15, 2024, she applied to reassign her Medicare benefits to Vertex – Northern California, and the contractor approved the application with an October 16, 2024 effective date of reassignment and a September 16, 2024 retrospective billing date.  CMS Exs. 1, 3.  Apparently, Petitioner intended to include both Vertex organizations in its November 15, 2024 application.  

Petitioner argues that her mistake was not “based on fraud, error, or negligence.”  P. Br. at 2.  She provided services in good faith, based on her prior experience.  She points to an earlier situation, in which CMS approved five months of retroactive payments to three

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physical therapists and argues that CMS has the “discretion to approve retroactive enrollment beyond 30 days when regulatory compliance and fairness support the request.”  Id. 

CMS may have the discretion to grant additional days of retrospective billing, but I do not.  I am bound by the regulations and have no authority to grant Petitioner the relief she requests.  It is well-settled that an administrative law judge may not grant relief based on equitable arguments.  Sokoloff, DAB No. 2972 at 9. 

Conclusion

I affirm the contractor’s reconsidered determination.  On February 18, 2025, Petitioner filed her subsequently-approved application to reassign Medicare benefits to Vertex Healthcare Solutions – Southern California.  Pursuant to 42 C.F.R. § 424.522(a), the reassignment was effective 30 days earlier – on January 19, 2025, and, pursuant to 42 C.F.R. § 424.521(a), December 20, 2024 is the earliest possible retrospective billing date.