Janine D. Miller MD Inc., DAB CR6848 (2026)

DECISION

This decision affirms the determination of Noridian Healthcare Solutions (Noridian), a contractor for the Centers for Medicare & Medicaid Services (CMS), that the effective date of Janine D. Miller MD Inc.’s (Petitioner’s) Medicare enrollment and billing privileges is September 18, 2024, with a retrospective billing date of August 19, 2024. 

I.  Procedural History and Decision on the Record

Noridian approved the enrollment application of Petitioner effective September 18, 2024, with retrospective billing privileges authorized beginning August 19, 2024.  Petitioner requested a reconsideration.  On June 19, 2025, Noridian issued an unfavorable reconsidered determination, upholding the effective date of Petitioner’s Medicare billing privileges.  On July 29, 2025, Petitioner requested a hearing before an administrative law judge (ALJ), claiming the effective billing date should be July 30, 2024, with

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retrospective billing authorized beginning July 1, 2024, based on an earlier enrollment application. 

On July 30, 2025, the Civil Remedies Division (CRD) acknowledged the hearing request and issued my Standing Prehearing Order (Prehearing Order).  On August 27, 2025, CMS timely filed a prehearing brief (CMS Br.), which included a motion for summary judgment, and twenty proposed exhibits (CMS Exs. 1-20).  Petitioner did not file a prehearing brief or proposed exhibits.  

On November 7, 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.  CRD Dkt. Entry No. 8.  I ordered Petitioner to file its prehearing exchange, along with a good cause explanation for filing the exchange late.  Id.  I also advised Petitioner that if it no longer wished to proceed with the hearing request, it could file a statement withdrawing the request.  Id.  On November 18, 2025, Petitioner filed a prehearing brief (P. Br.), which included a cross motion for summary judgment, and on November 19, 2025, Petitioner filed a response to the show cause order.  On November 20, 2025, I issued an Order Discharging the Order to Show Cause, finding good cause for Petitioner’s late filing.  CRD Dkt. Entry No. 11. 

On December 1, 2025, CMS filed a reply brief (CMS Reply).  On December 9, 2025, Petitioner filed a rebuttal (P. Reply) to CMS’s reply brief.  Petitioner may file a reply to CMS’s rebuttal statement if Petitioner shows good cause for doing so.  42 C.F.R.§ 498.17(b)(2).  I find Petitioner has shown good cause, and I accept Petitioner’s rebuttal statement.  

Petitioner did not object to any of CMS’s proposed exhibits; therefore, I admit CMS’s exhibits one through twenty into the record.  Prehearing Order ¶ 10; Civ. Remedies Div. P. § 14(e).  Petitioner did not offer any exhibits.  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).  Therefore, I deny the parties’ requests for summary judgment as moot.  

II.  Issue

Whether Noridian, acting on CMS’s behalf, had a legitimate basis to assign Petitioner’s Medicare enrollment and billing privileges as September 18, 2024, with a retrospective billing date of August 19, 2024. 

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III.  Jurisdiction

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

IV.  Findings of Fact

1.  Petitioner is a medical group practice located in Alaska.  Its NPI is 1538911755.  CMS Ex. 2 at 1; CMS Ex. 7 at 1. 

2.  On February 3, 2021, Noridian approved Dr. Janine Miller’s opt-out status effective December 9, 2020.  CMS Ex. 17.  Noridian informed Dr. Miller that her opt-out status would renew every two years unless she submitted a cancellation request at least 30 days prior to the end of the opt-out period.  Id. at 1. 

3.  On September 12, 2022, Noridian notified Dr. Miller that her opt-out status would automatically renew for a new two-year opt-out period on December 9, 2022.  CMS Ex. 20 at 1.  

4.  On July 30, 2024, Noridian received CMS-855B, CMS-855I, and CMS-855R applications for Petitioner.  CMS Ex. 2; CMS Ex. 3, CMS Ex. 4.  Petitioner indicated the business was a sole ownership business operation, and that Dr. Miller was reassigning her billing benefits to Petitioner.  CMS Ex. 2 at 2, 7; CMS Ex. 4.  The application did not list any other individuals who were reassigning benefits to Petitioner.  CMS Ex. 2. 

5.  On August 7, 2024, Noridian contacted Petitioner, acknowledging receipt of the electronic applications and requesting that Petitioner submit revisions and/or supporting documentation.  CMS Ex. 5.  

6.  On August 13, 2024, Noridian called Dr. Miller and confirmed that she was the sole owner of Petitioner.  CMS Ex. 11 at 1.  

7.  On August 14, 2024, Noridian notified Petitioner that the applications submitted on July 30, 2024, were closed and returned because Dr. Miller had opted out of Medicare and the opt-out period had not expired.  CMS Ex. 6 at 1.  The letter advised that, to cancel the current opt-out, Petitioner must submit a cancellation request at least 30 days before December 9, 2024.  Id.  It further instructed that, if Petitioner wished to reapply, it must submit a new Medicare enrollment application.  Id. 

8.  On September 18, 2024, Petitioner submitted new CMS-855B and CMS-855R applications, identifying Petitioner’s organization structure as a corporation and

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indicating a reassignment of billing rights from R.H., a non-physician practitioner.  CMS Ex. 7 at 2, 7-8; CMS Ex. 8. 

9.  By letter dated October 2, 2024, Noridian acknowledged receipt of Petitioner’s new Medicare enrollment applications and informed Petitioner that revisions and additional information were needed to process the applications.  CMS Ex. 9 at 1.  On October 2, 2024, Noridian received the requested revisions and additional information.  CMS Ex. 10. 

10.  On October 7, 2024, Noridian informed Petitioner that its initial enrollment application was approved with a retrospective billing date of August 19, 2024.  CMS Ex. 12 at 1 (although misidentifying August 19, 2024, as the effective date). 

11.  On May 30, 2025, Petitioner submitted a request for reconsideration to appeal the effective date of September 18, 2024, and a retrospective billing date of August 19, 2024.  CMS Ex. 13. 

12.  Initially, Noridian dismissed Petitioner’s reconsideration request as untimely, but CMS subsequently approved a good cause waiver of the timeliness requirement.  CMS. Ex. 14; CMS Ex. 15.  On June 19, 2025, Noridian denied Petitioner’s reconsideration request, finding that no errors were made regarding the determination of Petitioner’s effective date.  CMS Ex. 1.  Noridian determined that September 18, 2024, was the proper effective date with retrospective billing privileges beginning August 19, 2024.  Id. 

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, like Petitioner here, 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); see also 42 U.S.C. § 1395x(u); 42 C.F.R. § 400.202. 

A 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 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. 

CMS may return a supplier’s enrollment application for any of the reasons listed at 42 C.F.R. § 424.526(a).  These grounds typically involve situations where the supplier’s

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submission constitutes, in essence, a non-application.  86 Fed. Reg. 62,240, 62,357-58 (Nov. 9, 2021).  Returned applications are different from rejected applications:  

in that the latter:  (1) Does not automatically involve an invalid submission yet the application, for instance, failed to include certain information or documentation or contains erroneous data; and (2) can be remedied prior to any rejection via the provider’s or supplier’s submission of a corrected, revised, supplemented, or complete application. 

86 Fed. Reg. at 62,358. 

If CMS approves the enrollment application, the effective date of enrollment for a physician or nonphysician practitioner may only be the later of two dates:  the date when the practitioner filed an application for enrollment that was subsequently approved by a Medicare contractor charged with reviewing the application on behalf of CMS; or the date when the practitioner first began providing services at a new practice location.  42 C.F.R. § 424.520(d).  An enrolled physician or nonphysician practitioner may retrospectively bill Medicare for services provided to Medicare-eligible beneficiaries up to 30 days prior to the effective date of enrollment if circumstances precluded enrollment before the services were provided, or 90 days if a Presidentially-declared disaster precluded enrollment in advance of providing services.  42 C.F.R. § 424.521(a). 

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, “[a] provider or supplier is not afforded appeal rights if their application is returned . . . .”  42 C.F.R. § 424.526(b); see 42 C.F.R. § 498.3(b). 

VI.  Analysis

Petitioner submitted an initial enrollment application on September 18, 2024, and that application was processed to approval.  CMS Ex. 7; CMS Ex. 12.  Consistent with the regulations, CMS enrolled Petitioner with an effective date of September 18, 2024, and a retrospective billing date of August 19, 2024.  CMS Ex. 12; 42 C.F.R. § 424.520(d); 42 C.F.R. § 424.521(a).  Despite these undisputed facts, Petitioner requests an effective date of July 30, 2024, and a retrospective billing date of July 1, 2024, based on its earlier, returned application.  Request for Hearing; P. Br at 1-2, 8; see also CMS Ex. 1; CMS Ex. 6. 

Petitioner acknowledges that I generally lack authority to review the return of initial enrollment applications; however, it argues that I may review the return of its July 30, 2024 application because an action taken by a contractor outside the scope of its regulatory authority does not terminate an application.  P. Br. at 5 (citing Tri-Valley Family Medicine, Inc., DAB No. 2358 at 8-9 (2010)).  Petitioner argues the return of its

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application was not authorized as part of the exclusive list of permissible reasons for return as codified at 42 C.F.R. § 424.526(a)(1)-(13).  P. Br. at 1-2, 4-5.  Rather, Petitioner asserts the reassignment issue should have been a development matter under 42 C.F.R. § 424.525, and that Noridian should have given Petitioner 30 days to correct the error.  P. Br. at 6.  Petitioner further argues that the speed at which the September 18, 2024 application was approved shows that the application should be considered a “continuous processing episode” tied to the initial July 30, 2024 application.  P. Br. at 7 (citing Kasra Morshedizadeh, DAB No. CR5934 (2021)).  

CMS disagrees.  CMS Br. at 4, 6-7; CMS Reply at 1, 7-8.  CMS concedes that 42 C.F.R. § 424.526(a) does not specifically list a physician’s opt-out status as a reason to return an application to enroll in Medicare but argues the regulation does not state that the listed reasons for returning an application are exclusive.  CMS Reply at 3.  Rather, CMS argues that an opt-out agreement is analogous to a re-enrollment bar under § 424.535 or reapplication bar under § 424.530(f), which under 42 C.F.R. § 424.526(a)(6) is a permissible reason to return an initial enrollment application.  CMS Reply at 3. 

I need not decide whether the grounds listed in 42 C.F.R. § 424.526(a) are exhaustive because, as indicated by Noridian in its reconsidered determination, Petitioner’s July 30, 2024 application was returned “in accordance with 42 C.F.R. § 424.526[(a)](7)” stating “the application is not needed for (or is inapplicable to) the transaction in question.”  CMS Ex. 1 at 4. 

Petitioner sought Medicare billing privileges by submitting an application to reassign benefits from Dr. Miller, a practitioner who had opted out of Medicare.  CMS Ex. 2; CMS Ex. 3; CMS Ex. 4; CMS Ex. 20.  Under 42 C.F.R. § 405.425(a), Dr. Miller could not receive payment from Medicare or a Medicare Advantage plan, nor could any entity to which she reassigned her right to payment.  No other individuals reassigning benefits to Petitioner were listed on the application.  CMS Ex. 2.  Consequently, Petitioner was ineligible under Medicare rules to obtain a billing number or billing privileges.  CMS may return an enrollment application if “the application is not needed for (or is inapplicable to) the transaction in question.” 42 C.F.R. § 424.526(a)(7).  Because CMS determined Petitioner was not eligible for Medicare billing, the application was unnecessary.  

Petitioner asserts that reassignment from a non-eligible practitioner was a correctable error, arguing that its later reassignment with a different practitioner in its September 18, 2024 application, which was processed to approval, shows that the July application could be corrected.  P. Br. at 6-8.  Petitioner claims that where a second filing merely corrects the prior submission at the contractor’s direction, the effective date relates back to the initial filing date.  Id. 

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Petitioner relies on Tri-Valley (along with other non-binding ALJ-issued decisions).  P. Br. at 5-7; P. Reply at 5.  However, in Ramaswamy, the Board limited the scope of the holding in Tri-Valley, stating “that its decision in Tri-Valley addressed only ‘a narrow issue regarding how to apply a revised effective date regulation to an enrollment application that had been submitted before that regulation was in effect.’”  Karthik Ramaswamy, M.D., DAB No. 2563 at 8 (2014), aff’d Karthik Ramaswamy, M.D. v. Burwell, 83 F. Supp. 3d 846 (2015).  CMS amended the regulations January 1, 2022, to specifically allow the return of an enrollment application.  42 C.F.R. § 424.526; 86 Fed. Reg. 62,240-01, 62,420.  Further, the Board in Ramaswamy stated the following: 

We will not determine de novo that an application could have been processed to approval in the face of the contractor’s actual determination to deny the application because it was not approvable.  To do so would improperly use scope of review to revisit a legally binding and administratively final determination. 

Ramaswamy, M.D., DAB No. 2563 at 9. 

Petitioner’s argument that its initial application was correctable amounts to a request for de novo review of whether the application could have been approved.  Noridian affirmatively returned the July application to Petitioner.  CMS Ex. 6.  Thus, I do not have the authority to determine if the application that was returned could have been processed to approval.  42 C.F.R. § 424.526(b).  

Petitioner also states Noridian’s decision has resulted in over $90,000 in unreimbursed Medicare claims for services rendered to beneficiaries between July 1 and August 18, 2024, causing Petitioner significant financial hardship and undermined its continuity of care.  Request for Hearing at 1.  Petitioner’s arguments regarding financial hardship amount to a request for equitable relief.  However, the regulations do not provide this tribunal the authority to grant equitable relief.  Therefore, Petitioner’s effective date cannot be changed based upon the reasons provided.  US Ultrasound, DAB No. 2302 at 8 (2010) (“[n]either the ALJ nor the Board is authorized to provide equitable relief by reimbursing or enrolling a supplier who does not meet statutory or regulatory requirements.”). 

For the reasons stated above, I find that Noridian did not err in determining that September 18, 2024, the date that CMS received Petitioner’s applications that were subsequently approved, is the correct effective date of Petitioner’s Medicare enrollment and billing privileges.  73 Fed. Reg. 69,726, 69,769 (Nov. 19, 2008) (“We . . . have adopted the ‘date of filing’ as the date that the Medicare contractor receives a signed provider enrollment application that the Medicare contractor is able to process to approval.”); Alexander C. Gatzimos, MD, JD, LLC, DAB No. 2730 at 17 (2016).  Noridian also provided Petitioner with 30 days of retrospective billing privileges.  CMS

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Ex. 12.  Pursuant to the regulations, August 19, 2024, is the earliest possible retrospective billing date that Petitioner could have received.  42 C.F.R. § 424.521(a)(1)(i). 

VII.  Conclusion

For the reasons explained above, I affirm CMS’s determination that Petitioner’s effective date for Medicare enrollment and billing privileges is September 18, 2024, with retrospective billing allowed beginning on August 19, 2024.