James A. Kim M.D., A Professional Medical Corp., DAB CR6828 (2026)

DECISION

Petitioner, James A. Kim M.D., A Professional Medical Corp., is a supplier in California.  After the Medicare contractor deactivated its Medicare billing privileges, Petitioner submitted an application, seeking to reactivate its enrollment.  Acting on behalf of the Centers for Medicare & Medicaid Services (CMS), the contractor approved the February 3, 2025 application, with an effective billing date of February 3, 2025.  As a result, Petitioner’s Medicare coverage lapsed from October 1, 2024 through February 2, 2025.

Petitioner does not dispute that it did not timely respond to the contractor’s revalidation notification letter.  However, Petitioner instead states that the process took a couple of months and they continued to treat patients during that time.

Because Petitioner filed its subsequently approved reactivation application on February 3, 2025, February 3 is the earliest possible effective date for its Medicare reactivation.  See 42 C.F.R. § 424.540(d)(2).

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Background

The Medicare contractor, Noridian Healthcare Solutions (Noridian), approved Petitioner’s reactivation enrollment application effective February 3, 2025, with a gap in billing privileges from October 1, 2024 through February 2, 2025.  CMS Ex. 3.  Petitioner requested reconsideration and requested an earlier reactivation date because of clerical errors.  CMS Ex. 2.  In a reconsidered determination, dated June 19, 2025, a contractor hearing officer affirmed the February 3, 2025 reactivation date.  CMS Ex. 1.

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.  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 nineteen exhibits (CMS Exs. 1-19).  Petitioner did not file a brief but instead refiled its request for hearing.  Petitioner did file one exhibit (P. Ex. 1).  I also 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 and P. Ex. 1.

Discussion

1. On February 3, 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.

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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 provider or 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.  In a letter dated June 26, 2024, Noridian directed Petitioner to revalidate its Medicare enrollment records no later than September 30, 2024, and cautioned that if it failed to respond, the contractor could stop Petitioner’s Medicare billing privileges.  CMS Ex. 4.  The letter was sent to Petitioner’s mailing

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address at 361 Hospital Road, Suite 224, Newport Beach, California 92663.  Id; CMS Ex. 19.

On October 2, 2024, Noridian informed Petitioner that it was holding all payments on Petitioner’s Medicare claims because a revalidation application had not been received.  CMS Ex. 5.  The letter was sent to Petitioner’s correspondence address at 361 Hospital Road, Suite 224, Newport Beach, California 92663.  Id.; CMS Ex. 19.

On November 7, 2024, the contractor advised Petitioner that its Medicare billing privileges were stopped, effective October 1, 2024, because Petitioner failed to revalidate its enrollment records.  CMS Ex. 6.

On February 3, 2025, Petitioner submitted a revalidation application (CMS-855I).  CMS Ex. 17.

The February 3, 2025 application was processed to approval on March 27, 2025.  CMS Ex. 3.  February 3, 2025 is therefore the effective date for reactivating Petitioner’s billing privileges.  See 42 C.F.R. § 424.540(d)(2).

Petitioner admits that its billing privileges were deactivated because it did not respond to a re-credentialing process.  Petitioner Hearing Request (P. Hrg. Req.).  Petitioner requests an earlier reactivation date because they continued seeing patients.  Id.  Petitioner also filed an email correspondence purporting to show that it updated its mailing address in 2024.  P. Ex. 1.  Therefore, it appears that Petitioner is arguing that it did not respond to the letters from Noridian because they were not sent to Petitioner’s mailing address.  However, Petitioner’s Medicare enrollment record shows that Petitioner’s mailing address was 361 Hospital Road, Suite 224, Newport Beach, California 92663 through March 26, 2025.  CMS Ex. 19 at 2.  Since the request for revalidation, the stay of billing privileges and the deactivation of billing privileges letter were all sent before March 26, 2025, it is clear that the correspondences were sent to Petitioner’s correspondence address on record with Medicare.  This argument was also reviewed and rejected by the hearing officer.  CMS Ex. 1 at 5-6.

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); 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).  Petitioner may have continued to treat patients during the period they were deactivated but I have no authority to make a change to the effective date based on equity arguments.

Conclusion

Because Petitioner filed its subsequently-approved reactivation application on February 3, 2025, February 3 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).