Chester Psychological Assessmsnt & Therapy, LLC, DAB CR6825 (2026)

DECISION

This decision affirms the determination of Novitas Solutions (Novitas), a contractor for the Centers for Medicare & Medicaid Services (CMS), that October 17, 2024 is the reactivation effective date of Medicare enrollment and billing privileges for Chester Psychological Assessment & Therapy, LLC (hereinafter referred to as “Petitioner”). 

I. Background and Procedural History

On January 4, 2025, Petitioner timely requested a hearing before an administrative law judge (ALJ) to contest an unfavorable reconsideration determination regarding the effective date of its Medicare enrollment.  (P. RFH).  

On January 8, 2025, I issued an acknowledgment letter, my standing pre-hearing order (Standing Order), and the Civil Remedies Division Procedures (CRDP). 

On January 31, 2025, CMS filed a Motion for Summary Judgment and a pre-hearing brief (CMS Br.), along with 12 exhibits (CMS Exs. 1-12).  CMS did not offer witnesses or provide any sworn declarations. 

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Petitioner’s pre-hearing exchange was due on March 19, 2025.  Because Petitioner failed to file an exchange, an Order to Show Cause was issued on March 26, 2025. 

Petitioner responded to the Order to Show Cause on April 6, 2025, indicating that she did not intend to abandon her case (P. Br.).  Based on Petitioner’s response, the Order to Show Cause is discharged.  

II. Admission of Exhibits and Decision on the Record

Neither party identified witnesses.  Therefore, this case will be decided on the written record, without considering whether the standards for summary judgment are satisfied.  Standing Order ¶ 6(f); CRDP § 19(d). 

In the absence of objections, CMS Exs. 1-12 are admitted into evidence. 

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. Issue

Whether Novitas, acting on behalf of CMS, properly established October 17, 2024, as the reactivation effective date for Petitioner’s enrollment in the Medicare program.  

V. Legal Authorities

The Social Security Act (Act) establishes the enrollment process for providers and suppliers participating in Medicare or Medicare related programs.  42 U.S.C. §§ 1302, 1395cc(j).  Under the Act, “suppliers” are physicians or other practitioners, 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); 42 C.F.R. § 400.202.  Providers include hospitals, skilled nursing facilities, and home health agencies.  42 U.S.C. § 1395x(u); 42 C.F.R. § 400.202.  Petitioner is a “supplier.”  42 U.S.C. § 1395x(d); 42 C.F.R. § 400.202. 

A provider or supplier must be enrolled in the Medicare program in order to receive payment for covered items or services from either Medicare (in the case of an assigned claim) or a Medicare beneficiary.  42 C.F.R. § 424.505.  If enrolled, the provider or supplier receives billing privileges and is issued a valid billing number effective for the date a claim was submitted for an item that was furnished or a service that was rendered.  42 C.F.R. § 424.505. 

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Once enrolled, CMS may deactivate a provider or supplier’s Medicare billing privileges for any of the reasons listed at 42 C.F.R. § 424.540(a).  If CMS deactivates a supplier’s Medicare billing privileges, then the supplier may file a rebuttal to the deactivation.  42 C.F.R. §§ 424.545(b), 424.546(a)(1).  When CMS issues a determination based on a rebuttal, that determination is not an appealable initial determination.  42 C.F.R. § 424.546(f). 

The determination of a supplier’s effective date is an initial determination subject to ALJ review.  42 C.F.R. § 498.3(b)(15).  However, unlike the determination of a supplier’s effective date, “[e]nrollment applications that are rejected are not afforded appeal rights.”  42 C.F.R. § 424.525(d); see 42 C.F.R. § 498.3(b). 

VI. Findings of Fact

Dr. Nancy Sidhu is a psychologist, and the sole practitioner and owner of Chester Psychological Assessment & Therapy, LLC.  P. RFH; CMS Ex. 7 at 5. 

By notice letter dated April 30, 2024, CMS requested that Petitioner revalidate its Medicare enrollment record by July 31, 2024.  CMS Ex. 2.  The notice was mailed to Chester Psychological Assessment & Therapy, LLC at 1 Cristina Ct., Chester, NJ 07930 and warned that failure to respond may result in the deactivation of Medicare billing privileges and a gap in reimbursement.  Id.  

On August 10, 2024, Novitas issued a notice informing Petitioner that all Medicare payments were placed on hold due to Petitioner’s failure to revalidate its enrollment record.  CMS Ex. 4.  The notice warned that a failure to respond may result in deactivation of Petitioner’s Medicare enrollment.  Id.  The letter was addressed to Chester Psychological Assessment & Therapy, LLC at 1 Cristina Ct., Chester, NJ 07930.  Id.  Petitioner was advised to file a rebuttal to the deactivation if it disagreed with the determination.  Id.  The notice letter was also sent via email to Dr. Sidhu’s email address on the same date.  CMS Ex. 3.  

Novitas issued a determination on September 30, 2024, notifying Petitioner that its Medicare billing privileges were deactivated effective August 10, 2024, for failure to timely revalidate its enrollment record or for failure to timely respond to requests for additional information.  CMS Ex. 5.  Petitioner was informed that no claims would be paid after August 10, 2024.  Id.  Petitioner was also advised to file a rebuttal to the deactivation if it disagreed with the determination.  Id. 

Petitioner submitted an application to reactivate its deactivated Medicare enrollment on October 17, 2024.  CMS Ex. 6. 

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On October 23, 2024, Petitioner filed a rebuttal to contest the deactivation.  CMS Ex. 7.  By letter dated October 25, 2024, Novitas denied Petitioner’s rebuttal request because it was untimely filed.  CMS Ex. 8.  

On November 1, 2024, Novitas issued an initial determination informing Petitioner that its reactivation enrollment application was approved with an effective date of October 17, 2024.  CMS Ex. 9.  In a revised letter issued by Novitas on November 11, 2024, Petitioner was also informed that there would be a gap in billing privileges from August 10, 2024 through October 16, 2024 due to failure to fully revalidate during a previous revalidation cycle, and that Petitioner would not be reimbursed for services provided to Medicare beneficiaries during those dates.  CMS Ex. 11. 

Petitioner requested reconsideration of the reactivation date decision on November 5, 2024.  CMS Ex. 10.  Novitas issued an unfavorable reconsideration determination on November 12, 2024.  CMS Ex. 12. 

VII.  Analysis

CMS may deactivate Medicare billing privileges if a provider or supplier does not furnish complete and accurate information and all supporting documentation within 90 calendar days of receipt of notification from CMS to submit an enrollment application and supporting documentation, or resubmit and certify to the accuracy of its enrollment information.  42 C.F.R. § 424.540(a)(3).  Once Medicare billing privileges are deactivated, the effective date of the reactivation of billing privileges is the date on which the Medicare contractor received the provider’s or supplier’s reactivation submission that was processed to approval by the Medicare contractor.  42 C.F.R. § 424.540(d)(2). 

Neither the deactivation of billing privileges nor the rejection of an enrollment applications are “initial determinations” subject to ALJ review under 42 C.F.R. Part 498.  See 42 C.F.R. §§ 424.525(d), 498.3(b).  Because Petitioner’s rebuttal was untimely submitted, she was unable to challenge the initial determination.  The only issue to be addressed in this decision is whether CMS correctly determined the reactivation effective date.  

Petitioner notes that she did not receive the August 10, 2024 notice letter from Novitas until October 15, 2024.  P. RFH; CMS Ex. 10.  Petitioner moved during the COVID-19 pandemic and notes that mail is often sent to her old address, speculating that may have happened with the deactivation notices at issue in this case.  P. Br.  However, the record shows that the notice letters in question were sent to Petitioner’s new address at 1 Cristina Court, Chester, NJ.  CMS Exs. 2, 4.  Though she receives many emails from Medicare, Petitioner argues that she did not receive notifications, via email or phone call, regarding the revalidation.  P. Br. at 1.  However, I am not aware of, nor has Petitioner provided, any legal authority that requires CMS, or its contractors, to issue multiple 

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telephone calls and emails regarding revalidation.  Revalidation is required every five years.  42 C.F.R. § 424.515.  A Medicare program participant has a “duty to familiarize itself with the legal requirements for cost reimbursement.”  Heckler v. Cmty. Health Servs. of Crawford Cnty., Inc., 467 U.S. 51, 64 (1984).  This duty includes knowing the requirements for revalidation.  Petitioner spends much of her brief addressing the difficulties of being a Medicare provider, specifically as a sole provider.  See P. Br.  Though unfortunate, these challenges do not serve as a legal basis to determine that the reactivation effective date is incorrect.  The Board has ruled that difficulty with navigating the Medicare billing system (PECOS) does not present a legal basis for the Board or an ALJ to set an earlier effective date.  Chaplin Liu, M.D., DAB No. 2976 at 10 (2019). 

Lastly, Petitioner argues that she will suffer financial hardship if unable to bill for services provided during the deactivation period.  P. Br.  While I understand Petitioner’s concerns about the financial impacts of the billing gap during the deactivation, the applicable regulation does not provide for a retrospective or retroactive billing period, nor do I have the authority to add a period of retrospective or retroactive billing.  See 42 C.F.R. § 498.3(b)(15).  In addition, the regulations prohibit CMS from paying a supplier for items or services furnished to Medicare beneficiaries during the period of deactivation.  42 C.F.R. §§ 424.540(e), 424.555(b).  Finally, I have no authority to reverse CMS’s determination on equitable grounds.  Iowa Cancer Specialists, PC, DAB No. 3109 at 8 (2023) (citing Edward J.S. Picardi, M.D., DAB No. 3045 at 17 (2021); Anil Hanuman, D.O., DAB No. 3080 at 10 (2022)). 

In this case, Petitioner’s Medicare billing privileges were deactivated effective August 10, 2024, for failure to revalidate enrollment within the specified time period.  CMS Ex. 5.  This resulted in a gap in Medicare billing privileges from August 10, 2024 through October 16, 2024.  It is undisputed that on October 17, 2024, Petitioner filed a Medicare enrollment application that Novitas subsequently processed to approval.  CMS Exs. 6, 11.  Based on the evidence provided, I find that the hearing officer did not err in determining that Petitioner’s reactivation effective billing date is October 17, 2024.  

VIII. Conclusion

For the reasons stated above, I find that Novitas, on behalf of CMS, correctly determined that Petitioner’s reactivation effective date for Medicare enrollment and billing privileges is October 17, 2024.  Therefore, CMS’s reconsideration determination is AFFIRMED.