Vista Psychiatric and Primary Care Services, DAB CR6779 (2026)

DECISION

Noridian Healthcare Solutions (Noridian), a Medicare administrative contractor for the Centers for Medicare & Medicaid Services (CMS), approved the enrollment application of Vista Psychiatric and Primary Care Services (Petitioner) effective September 30, 2024, a date which was also upheld in a reconsidered determination.  Petitioner requests a hearing before an administrative law judge (ALJ) because it does not want a gap in its billing privileges from May 29, 2024, through September 29, 2024. 

My jurisdiction in this matter is limited to determining whether Noridian assigned the correct date for reactivation under the law.  I do not have jurisdiction to review Noridian’s decision to deactivate Petitioner’s billing privileges or to issue equitable relief.  As to the issue before me, I affirm Noridian’s determination that Petitioner’s effective date for reactivation of Medicare billing privileges is September 30, 2024, because that is the date Noridian received Petitioner’s reactivation application that it processed to approval.  

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I. Background

1. A. Procedural History

On February 20, 2025, Noridian issued an unfavorable reconsidered determination, finding that September 30, 2024, was the effective date of reactivation of Petitioner’s Medicare billing privileges.  On April 23, 2025, Petitioner timely filed a request for hearing (RFH) to dispute the reconsidered determination.  On April 24, 2025, the Civil Remedies Division (CRD) acknowledged the hearing request and issued my Standing Prehearing Order (Prehearing Order).  On May 28, 2025, CMS timely filed a prehearing exchange, which included its Brief and Motion for Summary Judgment (CMS Br.), and ten proposed exhibits (CMS Exs. 1-10).  

Petitioner did not file a prehearing exchange.  On July 16, 2025, I issued an Order to Show Cause explaining that Petitioner’s failure to file a prehearing exchange suggests it may have abandoned its request.  I ordered Petitioner to file its prehearing exchange, along with a good cause explanation for filing the exchange late.  I also advised Petitioner that it could file a statement withdrawing its hearing request if it no longer wished to proceed. 

Petitioner filed a response on July 21, 2025, explaining that it had uploaded an “Urgent Request for Reconsideration” on June 29, 2025, but there was a technical issue with DAB E-File.  Petitioner also filed a copy of the Urgent Request for Reconsideration, which is dated June 30, 2025, and addressed to Noridian.  In the filing, Petitioner describes issues with the mail distribution system at its office building and states it communicated with Medicare customer service during the revalidation process.  Petitioner also requests that Noridian be compelled to produce audio recordings or transcripts of phone calls related to its revalidation status. 

On July 22, 2025, I issued an Order discharging the show cause order based on Petitioner’s response.  Because it was unclear whether Petitioner’s submission was a second reconsideration request pending with Noridian, I asked CMS to clarify whether Noridian received Petitioner’s request and confirm its status, if available.  CMS was also given the opportunity to file a response to Petitioner’s records request.  CMS timely filed its response on August 21, 2025.  CMS responded that Noridian did not receive a second reconsideration request from Petitioner, and further noted that such a request is not permitted under the regulations.  CMS also argued that Petitioner’s records request is overbroad, immaterial, and irrelevant. 

After review of the filings and CMS’s response, I treat Petitioner’s July 21, 2025 filings (P. Br.) as its prehearing exchange.  Based on Petitioner’s contentions regarding its technical issues with DAB E-file, I find good cause for the untimely filing. 

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1. B. Petitioner’s Request for Records is Denied

Petitioner requests Noridian “be compelled to produce all audio recordings and/or transcripts of telephone communications pertaining to [Petitioner’s] Medicare revalidation status, specifically those interactions occurring between March 2024 to April 2025.”  P. Br. at 2.  Petitioner explains that the records are critical because they will demonstrate that it engaged with Medicare representatives on multiple occasions and was repeatedly informed that its revalidation application “was proceeding without impediment.”  Id.  Petitioner continues that the “evidence is essential to rebut Respondent’s assertion that the subsequent deactivation of billing privileges from May 29, 2024, through September 29, 2024, and the resulting non-reimbursable period, was justified.”  Id. 

The regulations allow a party to request, and an ALJ to issue, a subpoena if it is “reasonably necessary for the full presentation of a case.”  42 C.F.R. § 498.58(a).  The request must identify, inter alia, the documents to be produced and specify the pertinent facts the party expects to establish by the documents.  Id. § 498.58(c).  Also relevant here, 42 C.F.R. § 498.60(b)(1) requires me to inquire fully into all the matters at issue, and to receive into evidence the testimony of witnesses and any documents that are relevant and material.  A test for relevant evidence is available in the Federal Rules of Evidence, which are not controlling in this proceeding but provide excellent guidance: 

Evidence is relevant if: 

• (a)    it has any tendency to make a fact more or less probable than it would be without the evidence; and
• (b)    the fact is of consequence in determining the action.   

Fed. R. Evid. 401.  Applying the relevance test to the evidence Petitioner seeks, the requested evidence is not relevant to the issue I am authorized to decide in this case. 

I do not have the authority to review CMS’s deactivation of Petitioner’s billing privileges because that action is not an “initial determination” under the Secretary of Health and Human Services’ (Secretary) regulations which can be appealed and subject to ALJ review.  See 42 C.F.R. §§ 424.545(b), 498.3(b).  Therefore, even if there were audio recordings and transcripts and they showed that Noridian repeatedly assured Petitioner that the revalidation was advancing appropriately and the deactivation was a mistake, I do not have the authority to reverse or modify the deactivation date.  Consequently, the evidence Petitioner seeks is not reasonably necessary for the presentation of its case, and I deny Petitioner’s records request. 

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1. C. Admissions into the Record and Decision on the Record

Petitioner did not object to any of CMS’s proposed exhibits; therefore, I admit CMS’s exhibits 1 through 10 into the record.  Prehearing Order ¶ 10; Civ. Remedies Div. P. § 14(e).  Because neither party has proffered any witnesses, a hearing is not necessary.  I decide this case on the written record, meaning the parties’ written submissions and arguments, and without considering whether the standard for summary judgment is met.  Prehearing Order ¶ 13; Civ. Remedies Div. P. § 19(d).  I deny CMS’s summary judgment motion as moot.  

II. Issue

Whether Noridian, acting on CMS’s behalf, had a legitimate basis to assign September 30, 2024, as the effective date for the reactivation of Petitioner’s Medicare billing privileges. 

III. Jurisdiction

I have jurisdiction to hear and decide this case.  42 C.F.R §§ 498.3(b)(15), 498.5(l)(2); see also 42 U.S.C. § 1395cc(j)(8). 

IV. Findings of Fact

1. Petitioner is a medical group practice located in California. Its NPI is 1023463189, and PTAN is 199187.  CMS Ex. 2 at 1, 3.
2. On December 27, 2023, Noridian mailed a revalidation letter to Petitioner informing Petitioner that it was required to revalidate its Medicare enrollment record by March 31, 2024. CMS Ex. 1.
3. On April 10, 2024, Petitioner submitted a revalidation application. CMS Ex. 2.
4. On April 25, 2024, Noridian notified Petitioner by email that its application required revisions. CMS Ex. 3.  Noridian instructed that the revisions should be completed by May 25, 2024, to ensure timely processing.  Id.  The email also stated that Petitioner’s application could be rejected if Petitioner did not furnish the complete information within 30 days of the initial request.  Id.
5. By notice dated May 29, 2024, Noridian notified Petitioner that its Medicare billing privileges were deactivated effective May 29, 2024, because it did not timely revalidate its enrollment record, or because its revalidation application was rejected for failure to timely respond to requests for more information. CMS Ex. 4.  Noridian 

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5. informed Petitioner of the right to submit a rebuttal if Petitioner disagreed with the deactivation determination.  at 1-2.  
6. On August 12, 2024, Petitioner filed an enrollment application to reactivate its Medicare billing privileges. CMS Ex. 5.
7. On September 30, 2024, Noridian sent a notice to Petitioner explaining that it rejected its application because it was incomplete, despite its request for additional information that was sent by fax/mail on August 26, 2024. CMS Ex. 6.
8. On September 30, 2024, Petitioner submitted another enrollment application to reactivate its Medicare billing privileges. CMS Ex. 7 at 1.
9. On October 15, 2024, Noridian issued a notice of initial determination in which it approved Petitioner’s reactivation enrollment application. CMS Ex. 8.  The notice identified a gap “from May 29, 2024[,] through September 29, 2024.”   at 1.
10. By request dated November 15, 2024, Petitioner filed a reconsideration request. CMS Ex. 9. Petitioner stated that it was “appeal[ing] the denial of payment for claims submitted between May 29, 2024, and September 29, 2024.”  at 7.  Petitioner noted the complexity of the claims process, lack of clear and timely notification and the financial impact of the nonpayment of claims on the practice.  Id.  Petitioner also submitted documentation, including its application submissions in April 2024 and September 2024, and its response to Noridian’s request for corrections.  Id. at 9-34.
11. On February 20, 2025, Noridian issued an unfavorable reconsidered determination. CMS Ex. 10. Noridian explained that Petitioner’s enrollment was correctly deactivated effective May 29, 2024, due to a failure to fully revalidate.  at 4-5.  Noridian affirmed the effective date of reactivation, September 30, 2024, explaining that was the date of receipt of the application that was processed to approval.  Id. 

V. Conclusions of Law

1. Based on the reactivation enrollment application that Noridian approved in this case, the effective date for reactivation of Medicare billing privileges is the date the approved application was received by Noridian, e., September 30, 2024. 42 C.F.R. § 424.540(d)(2).
2. Petitioner is not eligible for a retrospective billing period to May 29, 2024, because CMS may not make payment to a supplier for items or services furnished to Medicare beneficiaries while the supplier’s Medicare billing privileges are deactivated. 42 C.F.R. §§ 424.540(e), 424.555(b).  

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VI. Analysis

The Social Security Act (Act) authorizes the Secretary to promulgate regulations governing the enrollment process for providers and suppliers.  42 U.S.C. §§ 1302, 1395cc(j).  Pertinent here, a “supplier” is “a physician or other practitioner, a facility, or other entity (other than a provider of services) that furnishes items or services” under the Medicare provisions of the Act.  42 U.S.C. § 1395x(d); see also 42 U.S.C. § 1395x(u).  

A supplier must enroll in the Medicare program to receive payment for covered Medicare items or services.  42 C.F.R. § 424.505.  The term “Enroll/Enrollment means the process that Medicare uses to establish eligibility to submit claims for Medicare-covered items and services, and the process that Medicare uses to establish eligibility to order or certify Medicare-covered items and services.”  42 C.F.R. § 424.502.  A supplier seeking Medicare billing privileges must “submit enrollment information on the applicable enrollment application.”  42 C.F.R. § 424.510(a)(1).  

To maintain Medicare billing privileges, suppliers must revalidate their enrollment information at least every five years.  42 C.F.R. § 424.515.  However, CMS reserves the right to perform revalidations at any time.  42 C.F.R. § 424.515(d), (e).  When CMS notifies providers and suppliers that it is time to revalidate, the providers or suppliers must submit the appropriate enrollment application, accurate information, and supporting documentation within 60 calendar days of CMS’s notification.  42 C.F.R. § 424.515(a)(2). 

CMS can deactivate an enrolled supplier’s Medicare billing privileges if the enrollee fails to comply with revalidation requirements.  42 C.F.R. § 424.540(a)(3).  When CMS deactivates Medicare billing privileges, “[n]o payment may be made for otherwise Medicare covered items or services furnished to a Medicare beneficiary.”  42 C.F.R. § 424.555(b).  

Here, Noridian, by notice letter dated May 29, 2024, deactivated Petitioner’s billing privileges because its application was rejected for failure to timely respond to Noridian’s requests for more information.  CMS Ex. 4.  As explained above, I do not have the authority to review CMS’s decision to deactivate as it does not constitute an initial determination.1 See 42 C.F.R. §§ 424.545(b), 498.3(b). 

Turning to the action within my authority, the reactivation date, I find no error in Noridian’s determination.  If CMS deactivates a supplier’s billing privileges due to an 

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untimely or incomplete response to a revalidation request, the enrolled supplier may apply for CMS to reactivate its Medicare billing privileges by recertifying its enrollment information that is on file or, if deemed appropriate by CMS, complete a new enrollment application.  42 C.F.R. § 424.540(b)(1), (2).  The effective date of reactivation is the date on which the Medicare contractor received the supplier’s reactivation submission that was processed to approval.  42 C.F.R. § 424.540(d)(2).  

In this case, the record shows that Petitioner submitted applications on multiple dates: April 10, 2024, August 12, 2024, and September 30, 2024.  CMS Exs. 2, 5, and 7.  The application submitted in April 2024 required corrections, but there is no evidence Petitioner responded to the request for corrections.  CMS Ex. 3.  The application submitted in August 2024 also required corrections.  CMS Ex. 6.  Noridian indicated in its rejection letter that corrections were requested, but the application remained incomplete.2 Id.  The application Petitioner submitted on September 30, 2024, was processed to approval.  CMS Ex. 8.  Therefore, the effective date is September 30, 2024. 

I recognize that Petitioner does not want a gap in its Medicare billing privileges as well as Petitioner’s contentions regarding its office building’s mail delivery issues and its communications with CMS throughout the revalidation process.  However, the effective date provision for reactivation does not provide for a retrospective or retroactive period of billing.  See 42 C.F.R. § 424.540(e).  To the extent Petitioner’s request for relief is based on principles of equity, I cannot grant such relief.  An ALJ is not authorized to provide equitable relief by reimbursing or enrolling a supplier that does not meet statutory or regulatory requirements.  US Ultrasound, DAB No. 2302 at 8 (2010).  

VII. Conclusion

For the reasons explained above, the reactivation effective date for Petitioner’s Medicare billing privileges is September 30, 2024.