Whites Family Clinic, LLC, DAB CR6764 (2025)

DECISION

Petitioner, Whites Family Clinic, LLC, is a medical practice located in Arkansas.  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 January 23, 2025.  As a result, Petitioner’s Medicare billing privileges lapsed from December 13, 2024, through January 22, 2025. 

Citing errors in the mailing address and CMS’s good cause provisions, Petitioner asks that the gap in billing privileges be waived. 

Because Petitioner filed its subsequently-approved reactivation application on January 23, 2025, January 23, 2025 is the earliest possible effective date for its Medicare reactivation.  See 42 C.F.R. § 424.540(d)(2). 

Background

The Medicare contractor, Novitas Solutions, Inc., approved Petitioner’s reactivation enrollment application effective January 23, 2025, with a gap in billing privileges from December 13, 2024, through January 22, 2025.  CMS Ex. 9.  Petitioner requested 

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reconsideration, asserting that “the address on the letter is incorrect” and that Petitioner was unaware that its October 31, 2024 revalidation application had been closed.  CMS Ex. 1.  Petitioner further stated that the letter did not state that it would not be reimbursed for services provided to Medicare patients from December 13, 2024 to January 22, 2025.  Id.  In a reconsidered determination, dated April 16, 2025, a Provider Enrollment Hearing Specialist affirmed the January 23, 2025 reactivation date.  CMS Ex. 10 at 3-4.  

Petitioner appeals, and the matter is now before me. 

CMS moves for summary judgment.  However, because neither party proposes any witnesses, an in-person hearing would serve no purpose.  See Standing Order at 9-10 (May 6, 2025).  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 10 exhibits (CMS Exs. 1-10).  Petitioner submitted a response to CMS’s motion as well as two exhibits (P. Exs. 1-2). 

In the absence of any objections, I admit into evidence CMS Exs. 1-10 and P. Exs. 1-2.  See Standing Order at 10.  

Discussion

1. 1. On January 23, 2025, 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).1

Enrollment.  Petitioner participates in the Medicare program as a “supplier” of services.  See Social Security Act (Act) § 1861(d); 42 C.F.R. § 498.2.  To receive Medicare payments for the services furnished to program beneficiaries, a supplier must enroll in the program.  Act §§ 1834(j), 1835(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 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 

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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 a physician practice organization 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). 

Because this case involves reactivation, additional regulations apply. 

Reactivation.  The regulations governing reactivation differ in significant ways from the enrollment regulations.  See 86 Fed. Reg. 62,240, 62,359-60 (Nov. 9, 2021). 

To maintain its billing privileges, a supplier must resubmit and recertify the accuracy of its enrollment information every five years.  42 C.F.R. § 424.515.  CMS may also perform off-cycle revalidations at any time.  42 C.F.R. § 425.515(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). 

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). 

Petitioner’s deactivation and reactivation.  Here, in a letter dated July 31, 2024, the contractor directed Petitioner to revalidate its Medicare enrollment records no later than October 31, 2024, and cautioned that if the practice failed to respond, the contractor could stop its Medicare billing privileges.  CMS Ex. 2. 

On October 30, 2024, Petitioner filed a CMS-855B Application in response to the July 31, 2024 letter.  CMS Ex. 3.  In that application, Petitioner listed Jasmine Carson at 2900 Saint Michael Drive, Suite 409, Texarkana, Texas 75503 (Texarkana address) as an enrollment application contact person.  Id. at 6. 

On November 13, 2024, Novitas sent a letter to Petitioner at the Texarkana address requesting that Petitioner verbally verify its special payments address.  CMS Ex. 4.  The letter further advised that Petitioner’s “application will not continue processing until you have contacted [Novitas].”  Id. 

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In a letter dated December 13, 2024, sent to the Texarkana address, the contractor advised Petitioner that, pursuant to 42 C.F.R. § 424.540(a)(3), its Medicare billing privileges were deactivated, effective December 13, 2024, because it did not timely respond to the request for more information.  CMS Ex. 5 at 1.  The letter advised Petitioner that the contractor would not pay any Medicare claims after that date.  Id. 

On January 14, 2025, Petitioner submitted a CMS-855B Medicare reactivation application.  CMS Ex. 6.  In a letter dated January 22, 2025 Novitas notified Petitioner that they were closing the enrollment request and returning the application because the application was withdrawn.  CMS Ex. 7. 

On January 23, 2025, Petitioner submitted a reactivation application that the contractor processed to approval.  CMS Exs. 8, 9.  January 23, 2025 is therefore the effective date for reactivating Petitioner’s billing privileges.  See 42 C.F.R. § 424.540(d)(2). 

Petitioner explains that it was unaware of the deactivation until January 2025, when it received the letter from the contractor closing the January 14, 2025 application.  Petitioner argues that it was denied the opportunity to comply because the correspondence regarding its applications were sent to the Texarkana address instead of its correspondence address.3 See P. Br.  As noted above, Novitas did send the request for additional information and the deactivation letter to the address listed in Petitioner’s application as the enrollment application contact person.  

Petitioner also asserts that CMS should use its good cause authority to waive the gap in billing because Petitioner did not willfully ignore the contractor’s request for additional information and continued to provide necessary treatment to its patients.  P. Br. at 5. 

But 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-

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• 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). 

Further, I have no authority to review a deactivation or rejected application.  Michael B. Zafrani, M.D., DAB No. 3075 at 3, 8; Howard M. Sokoloff, DPM, MS, Inc., DAB No. 2972 at 6 (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 grant an earlier effective date based on equitable or policy arguments.  Howard M. Sokoloff, DPM, MS, Inc., DAB No. 2972 at 9.  

Conclusion

Because Petitioner filed its subsequently-approved reactivation application on January 23, 2025, January 23, 2025 is the earliest possible effective date.  See 42 C.F.R. § 424.540(d)(2).  

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