Munster Eye Care Associates, P.C., DAB CR6852 (2026)

DECISION

Novitas Solutions, Inc. (Novitas), a Medicare administrative contractor for the Centers for Medicare & Medicaid Services (CMS), approved the enrollment application of Munster Eye Care Associates, P.C. (Petitioner) effective March 4, 2025, a date which Chags Health Information Technology, LLC (C-HIT) 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 January 14, 2025, through March 3, 2025. 

My jurisdiction in this matter is limited to determining whether Novitas assigned the correct date for reactivation under the law.  I do not have jurisdiction to review Novitas’s decision to deactivate Petitioner’s billing privileges or to issue equitable relief.  As to the issue before me, I affirm the determination that Petitioner’s effective date for reactivation of Medicare billing privileges is March 4, 2025, because that is the date Novitas received Petitioner’s reactivation application that it processed to approval.  

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I.  Procedural History and Decision on the Record

On September 16, 2025, C-HIT issued an unfavorable reconsidered determination related to the effective date of reactivation of Petitioner’s Medicare billing privileges.  On September 17, 2025, Petitioner timely requested a hearing to dispute the reconsidered determination.  On September 18, 2025, the Civil Remedies Division (CRD) acknowledged the hearing request and issued my Standing Prehearing Order (Prehearing Order).  

On December 5, 2025, CMS timely filed a prehearing brief, which included a Motion for Summary Judgment, Memorandum in Support (CMS Br.), and six proposed exhibits (CMS Exs. 1-6).  Petitioner timely filed a response to CMS’s Motion for Summary Judgment (P. Response). 

Petitioner did not object to any of CMS’s proposed exhibits; therefore, I admit CMS’s exhibits 1 through 6 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).  Therefore, I deny CMS’s summary judgment motion as moot.  

II.  Issue

Whether Novitas, acting on CMS’s behalf, had a legitimate basis to assign March 4, 2025, 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 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) supplier located in Indiana.  Its NPI is 1407059389, and PTAN is 0810470001.  CMS Ex. 4 at 1. 

2.  June 28, 2024, Novitas mailed a revalidation letter to Petitioner’s practice location address, informing Petitioner that it was required to revalidate its Medicare enrollment record by September 30, 2024.  CMS Ex. 1. 

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3.  Novitas mailed a notice letter informing Petitioner that its Medicare billing privileges were deactivated effective January 14, 2025, because it did not timely revalidate its enrollment record.  CMS Ex. 2 at 1.  The notice letter advised Petitioner of its right to file a rebuttal if Petitioner did not believe the deactivation determination was correct.  Id. at 1-2. 

4.  On March 4, 2025, Petitioner filed an enrollment application to reactivate its Medicare billing privileges.  CMS Ex. 3. 

5.  On June 18, 2025, Novitas issued an initial determination in which it approved Petitioner’s revalidation application with an effective date of March 4, 2025.  CMS Ex. 4. 

6.  On June 25, 2025, Petitioner filed a reconsideration request.  CMS Ex. 5.  Petitioner stated that it did not receive the revalidation request or the notice letter informing it of its deactivation.  Id. at 2.  Petitioner explained that it first learned of the deactivation when its claim was denied.  Id.  Petitioner states that upon learning of its deactivation, it immediately acted and completed a revalidation request.  Id.  Because of Petitioner’s history of good standing, compliance, and the steps it has taken to avoid similar issues in the future, Petitioner requested that the effective date be changed to January 14, 2025.  Id. at 2-3. 

7.  On September 16, 2025, C-HIT issued an unfavorable reconsidered determination.  CMS Ex. 6.  C-HIT reviewed the record and noted that the revalidation request was mailed to Petitioner on June 28, 2024, and that a letter notifying Petitioner of the deactivation of its billing privileges, effective January 14, 2025, was mailed on the same date.  Id. at 2.  C-HIT further stated that Petitioner submitted its reactivation enrollment application on March 4, 2025.  Id. at 4.  Based on these facts, C-HIT concluded there was no error in the reactivation effective date resulting in the gap of billing privileges.  Id. 

V.  Conclusions of Law

1.  Based on the reactivation enrollment application that Novitas approved in this case, the effective date for reactivation of Medicare billing privileges is the date Novitas received the approved application, i.e., March 4, 2025.  42 C.F.R. § 424.540(d)(2). 

2.  Petitioner is not eligible for a retrospective billing period to January 14, 2025, 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

Petitioner does not want a gap in its Medicare billing privileges from January 14, 2025, through March 3, 2025.  This gap was created when Novitas deactivated Petitioner’s Medicare billing privileges because Petitioner failed to revalidate its enrollment records.  Throughout this process, Petitioner maintains that it did not receive Novitas’s June 28, 2024 notice of revalidation, nor the deactivation notice it issued on January 14, 2025.  CMS Ex. 5 at 2-3; Request for Hearing; P. Response.  Petitioner argues that there is no proof it ever received the Medicare DME revalidation or deactivation notices that CMS claims to have mailed, noting that the letters were not sent by certified mail and no email notifications were provided.  P. Response at 1.  Petitioner emphasizes its long history of compliance and states that it would never intentionally allow a lapse in any of its contracts.  Id. at 1-2.  Finally, in response to CMS’s citations to effective‑date regulations that do not apply here, Petitioner asserts that, under 42 C.F.R. § 424.521, it is entitled to at least 30 days of retrospective billing privileges because it met all Medicare program and licensure requirements and continued providing services without any notice of deactivation.  Id.  

At the outset I clarify that while providers and suppliers are subject to the same general enrollment and revalidation rules, DMEPOS suppliers (such as Petitioner) are subject to additional, unique supplier requirements.  For example, while other types of suppliers must revalidate their enrollment information at least every five years to maintain Medicare billing privileges, DMEPOS suppliers must revalidate every three years.  Compare 42 C.F.R. § 424.515, with 42 C.F.R. § 424.57(g).  Likewise, even though the effective date regulations are inapplicable here because the issue is Petitioner’s reactivation, DMEPOS suppliers are subject to different effective date rules than other providers and suppliers.  Compare 42 C.F.R. § 424.520(d), with id. § 424.520(c).  Notably, the regulations do not permit retrospective billing for DMEPOS suppliers.  42 C.F.R. § 424.521(a).  

These distinctions aside, all suppliers must enroll in the Medicare program to receive payment for covered Medicare items or services.  42 C.F.R. § 424.505; see also 42 U.S.C. § 1395cc(j)(1)(A) (authorizing the Secretary of the U.S. Department of Health & Human Services (Secretary) to establish regulations addressing the enrollment of providers and suppliers in the Medicare program).  Under the Secretary’s regulations, an enrolled supplier must revalidate to maintain Medicare billing privileges and when CMS instructs a supplier to revalidate, the supplier 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 may deactivate an enrolled supplier’s Medicare billing privileges if the supplier fails to comply with revalidation requirements.  42 C.F.R. § 424.540(a)(3).  When CMS deactivates billing privileges due to an untimely response to a revalidation request, the

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supplier may seek reactivation by recertifying the enrollment information on file or, if CMS deems it appropriate, by submitting 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 it processed to approval.  Id. § 424.540(d)(2).  Finally, “[a] provider or supplier may not receive payment for services or items furnished while deactivated . . . .”  Id. § 424.540(e); see also 42 C.F.R. § 424.555(b). 

I have carefully considered Petitioner’s arguments, and I have no reason to question their veracity.  However, even accepting them as true, I am unable to grant the requested relief because the governing regulations set forth above do not permit it. 

Petitioner’s situation involves Novitas’s determination to deactivate Petitioner’s Medicare billing privileges effective January 14, 2025, and to reactivate Petitioner’s billing privileges effective March 4, 2025.  Of these actions, only the date of reactivation is an initial determination that may be appealed to an ALJ.  42 C.F.R. § 498.3(b)(15).  I have no authority to review CMS’s deactivation of Petitioner’s billing privileges, because that action is not an “initial determination” under the regulations which can be appealed and subject to ALJ review.  See 42 C.F.R. § 498.3(b); see also 42 C.F.R. §§ 424.545(b) (stating a provider or supplier whose billing privileges are deactivated may file a rebuttal with CMS), 424.546(f) (a deactivation determination is not an appealable initial determination). 

Here, Novitas, by notice letter dated January 14, 2025, deactivated Petitioner’s billing privileges because Petitioner failed to timely revalidate.  CMS Ex. 2.  And while I acknowledge Petitioner’s contention it did not receive the notice, which contained information about its rebuttal rights and therefore presumably prevented it from exercising those rights, there is no evidence that Petitioner filed a rebuttal, the only recourse available to it to rebut the deactivation.  42 C.F.R. §§ 424.545(b), 424.546.  I reiterate that I do not have the authority to review CMS’s decision to deactivate because it is not an initial determination.  See 42 C.F.R. §§ 498.3(b), 424.546(f). 

Turning to the issue over which I have authority to review, I find no error in Novitas’s determination.  The evidence shows that Novitas received Petitioner’s application on March 4, 2025, and this application was processed to approval; therefore, the effective date is March 4, 2025.  CMS Ex. 3.  Moreover, the effective date provision for reactivation does not provide for a retrospective or retroactive period of billing.  See 42 C.F.R. § 424.540(d)(2). 

Regarding Petitioner’s assertions that it has a long history of being compliant and in good standing, and that a disruption with its billing agent caused by a large‑scale cyberattack prevented it from learning of the deactivation before March 4, 2025, I again have no basis to doubt these statements.  However, these contentions ultimately amount to a request for

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equitable 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) (citing Regency on the Lake, DAB No. 2205 (2008)).  The regulations are clear that a supplier may not receive payment for services or items furnished while deactivated; therefore, I have no authority to direct the contractor to allow retrospective reimbursement.  42 C.F.R. § 424.540(e); 42 C.F.R. § 424.555(b). 

VII.  Conclusion

For the reasons explained above, the reactivation effective date for Petitioner’s Medicare billing privileges is March 4, 2025.