ORD Physiatry PC, CR6824 (2026)

DECISION

Petitioner, ORD Physiatry PC, is a supplier in New Jersey.  After the Medicare contractor deactivated its Medicare billing privileges, Petitioner submitted multiple applications, seeking to reactivate its enrollment.  Acting on behalf of the Centers for Medicare & Medicaid Services (CMS), the contractor approved the December 9, 2024 application, with an effective billing date of December 9, 2024.  As a result, Petitioner’s Medicare coverage lapsed from August 16, 2024 through December 8, 2024. 

Petitioner does not dispute that it did not timely and completely respond to the contractor’s requests for verification of information.  However, Petitioner instead argues that CMS reached out to a nonworking telephone number which resulted in the rejected applications and asks that the lapse in billing privileges be rescinded. 

Because Petitioner filed its subsequently approved reactivation application on December 9, 2024, December 9 is the earliest possible effective date for its Medicare reactivation.  See 42 C.F.R. § 424.540(d)(2). 

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I. Background

The Medicare Administrative Contractor, Novitas Solutions (Novitas), approved Petitioner’s reactivation enrollment application effective December 9, 2024, with a gap in billing privileges from August 16, 2024, through December 8, 2024.  CMS Ex. 16.  Petitioner requested reconsideration and requested a July 1, 2024 reactivation date.  CMS Ex. 17.  In a reconsidered determination, dated April 15, 2025, a Notivas hearing officer affirmed the December 9, 2024 reactivation date.  CMS Ex. 19.  

Petitioner timely requested a hearing before an administrative law judge on April 23, 2025.  Docket (Dkt.) Numbers (Nos.) 1-1a.  This case was transferred to me on December 30, 2025.  Dkt. No. 13. 

CMS moves for summary judgment.  However, because neither party proposes any witnesses, an in-person hearing would serve no purpose.  I may therefore decide this case based on the written record, without considering whether the standards for summary judgment are satisfied.  Standing Order at ¶ 13; Civil Remedies Division Procedures at ¶ 19. 

CMS submits its motion and brief (CMS Pre Hearing Brief) with nineteen exhibits (CMS Exs. 1-19).  Petitioner did not file a brief or any other documents in response to CMS’s submissions but instead refiled its request for hearing (Petitioner Req. for Hearing) after the July 8, 2025 show cause order.  I consider the arguments and exhibits contained within Petitioner’s hearing request.  See Anil Hanuman, D.O., DAB No. 3080 at 12 (2022). 

In the absence of any objections, I admit into evidence CMS Exs. 1-19.  

II. Issues

Whether the effective date of Petitioner’s reactivated Medicare benefits is December 9, 2024. 

III. Jurisdiction

I have jurisdiction to hear and decide this case.  42 C.F.R. § 498.3(b)(15); Victor Alvarez, M.D., DAB No. 2325 at 8-12 (2010); see also 42 U.S.C. § 1395cc(j)(8)

IV. Discussion

1. 1. On December 9, 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).1

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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 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 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). 

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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.  In a letter dated October 31, 2023, Novitas directed Petitioner to revalidate its Medicare enrollment records no later than January 31, 2024, and cautioned that if it failed to respond, Novitas could stop Petitioner’s Medicare billing privileges.  CMS Ex. 2 at 1. 

On May 7, 2024, Novitas informed Petitioner that it was holding all payments on Petitioner’s Medicare claims because Petitioner did not revalidate its enrollment record.  CMS Ex. 3.  The letter was sent to Petitioner’s correspondence address in New York and an additional practice address in New Jersey.  Id. at 1 and 3. 

On August 16, 2024, Novitas advised Petitioner that its Medicare billing privileges were stopped, effective August 16, 2024, because Petitioner failed to revalidate its enrollment record.  CMS Ex. 4 at 1. 

On September 4, 2024, Petitioner submitted a revalidation application (CMS-855I).  CMS Ex. 5 at 1.  Included with its application were changes to Petitioner’s Electronic Fund Transfer information and Special Payments Address.  Id. at 2 and 6. 

In response to the application, Novitas sent a verification request letter dated September 17, 2024, to the correspondence address Petitioner listed in its application.  CMS Ex. 7.  CMS also sent a verification request to the email address provided for Bina Batheja, a contact person listed in the application.  CMS Ex. 5 at 5; CMS Ex. 7 at 1.  The verification requests asked Petitioner to confirm the information provided in the revalidation application within 30 calendar days.  CMS Ex. 7 at 1. 

On October 17, 2024, Novitas rejected the September 4, 2024 application based on Petitioner’s failure to respond to the verification request letter and email.  CMS Ex. 8 at 1. 

Petitioner submitted another revalidation application (CMS-855I), which Novitas received on October 18, 2024.  CMS Ex. 9 at 1.  The application again contained changes to Petitioner’s Electronic Fund Transfer information and Special Payments Address.  Id. at 2 and 6.  

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On November 5, 2024, Novitas sent a verification request letter to the correspondence address listed in Petitioner’s application.  CMS Ex. 11.  Novitas also attempted to contact Petitioner’s representative, Marc Rosenblatt, by telephone on October 30, 2024, November 4, 2024, November 5, 2024, and December 5, 2024 to verify the proposed changes in the revalidation application.  CMS Ex. 10.  Novitas used the phone number listed in Petitioner’s enrollment record.  Id.  Novitas also attempted to contact Petitioner using the phone number listed in the correspondence address in the October 18, 2024 revalidation application.  Id.; see also CMS Ex. 9 at 2 and 5.  Petitioner did not respond to the voicemails or the November 5, 2024 verification request letter.  CMS Pre-Hearing Brief at 9; Petitioner Req. for Hearing. 

On December 9, 2024, Novitas rejected the November 5, 2024 application based on Petitioner’s failure to contact Novitas to verify its Electronic Fund Transfer information and Special Payment Address.  CMS Ex. 12 at 1. 

On December 9, 2024, Petitioner submitted a third reactivation application.  CMS Ex. 13 at 1.  The application again contained changes to Petitioner’s Electronic Fund Transfer information and Special Payments Address.  Id. at 2 and 6.  On December 19, 2024, Novitas sent a verification letter to Petitioner’s correspondence address.  CMS Ex. 14.  The contractor sent a development request email to Jamie Cassella, Marc Rosenblatt, and Melanie Magnon on January 16, 2025 after apparently speaking with Marc Rosenblatt.  CMS Ex. 15; CMS Pre-Hearing Brief at 10. 

The December 9, 2024 application was processed to approval on February 3, 2025.  CMS Ex. 16 at 1.  December 9, 2024 is therefore the effective date for reactivating Petitioner’s billing privileges.  See 42 C.F.R. § 424.540(d)(2). 

Petitioner explains that the phone number CMS tried to contact its office with had been inactive for years.  Petitioner Req. for Hearing.  Petitioner asserts that CMS should have used the other contact information supplied in its application.  Id.  Petitioner then requests an effective billing date of July 1, 2024.  Id. 

But a supplier may not receive payment for services or items furnished while deactivated.  42 C.F.R. § 424.540(e); 42 C.F.R. § 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 

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• 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. d/b/a Baptist Health Family Clinic Lakewood, DAB No. 2929 at 7-9 (2019); and 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 (2019).  

V. Conclusion

Because Petitioner filed its subsequently-approved reactivation application on December 9, 2024, December 9 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).