Four Corners Wellness Center, LTD., DAB CR6857 (2026)

DECISION

The effective date of enrollment in the Medicare program for Petitioner, Four Corners Wellness Center, LTD., is June 4, 2025, with a retrospective billing period starting May 5, 2025.

I. Background and Procedural History

On November 11, 2025, Petitioner requested a hearing before an administrative law judge seeking an earlier effective date of enrollment in the Medicare program.  On November 14, 2025, the Civil Remedies Division acknowledged receipt of the hearing request and issued my Standing Order as well as the Civil Remedies Division Procedures (CRDP).  On January 5, 2026, CMS filed a brief/motion for summary judgment (CMS Br.) and 10 proposed exhibits.  Petitioner did not file a prehearing exchange.

II. Admission of Evidence

Absent objection, I admit CMS’s proposed exhibits into the record.

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III. Decision on the Written Record

I directed the parties to submit written direct testimony for any witnesses they wanted to offer.  Standing Order ¶ 11; see also CRD Procedures § 16(b).  I also informed the parties as follows:

If the parties either do not file any written direct testimony or the parties do not request to cross-examine any of the witnesses from whom written direct testimony has been submitted, I will consider such actions by the parties to serve as a constructive request for a decision on the written record because there will be no reason to hold an in-person hearing.

Standing Order ¶ 7(g)(iii); see also CRD Procedures § 19(d).  I further advised:  “Unless a hearing is required for cross-examination of a witness or witnesses, the record will be closed and the case will be ready for a decision after all the submission deadlines have passed.”  Standing Order ¶ 14.

Neither party submitted written direct testimony from any witnesses and all submission deadlines have passed.  Therefore, I decide this case on the written record.  Anil Hanuman, D.O., DAB No. 3080 at 11-12 (2022); CRD Procedures § 19(d).

IV. Issue

Whether CMS assigned the correct effective date for Petitioner’s Medicare enrollment and billing privileges.

V. Jurisdiction

I have jurisdiction to decide the issue in this case.  42 C.F.R. § 498.3(b)(15).

VI. Findings of Fact

1. On June 25, 2024, a CMS contractor received a CMS-855B enrollment application from Petitioner.  CMS Ex. 1.
2. In an August 21, 2024 notice, the CMS contractor rejected Petitioner’s enrollment application because the CMS contractor requested additional information, but Petitioner did not provide it.  CMS Ex. 2.
3. On September 17, 2024, the CMS contractor received another CMS-855B enrollment application from Petitioner.  CMS Ex. 3.

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4. In a November 6, 2024 notice, the CMS contractor rejected Petitioner’s enrollment application because the CMS contractor requested additional information, but Petitioner did not provide it.  CMS Ex. 4.
5. On March 20, 2025, the CMS contractor received a CMS-855I enrollment application from Petitioner.  CMS Ex. 5.
6. In an April 29, 2025 notice, the CMS contractor rejected Petitioner’s enrollment application because the CMS contractor requested additional information, but Petitioner did not provide it.  CMS Ex. 6.
7. On June 4, 2025, the CMS contractor received a CMS-855B enrollment application from Petitioner.  CMS Ex. 7.
8. On July 8, 2025, the CMS contractor approved Petitioner’s enrollment application and set May 5, 2025, as the effective date for Petitioner’s Provider Transaction Access Number (PTAN).  CMS Ex. 8 at 1.
9. On August 2, 2025, Petitioner requested reconsideration seeking an earlier effective date for Medicare billing privileges.  CMS Ex. 9.
10. On September 10, 2025, the CMS contractor issued a reconsidered determination affirming May 5, 2025, as the effective date for Petitioner’s PTAN.  CMS Ex. 10 at 3.

VII. Conclusions of Law and Analysis

1. The effective date for Petitioner’s enrollment/billing privileges in the Medicare program as a clinic/group practice is June 4, 2025, and Petitioner’s retrospective billing period commenced on May 5, 2025.

The Social Security Act (Act) authorizes the Secretary of Health and Human Services (Secretary) to promulgate regulations governing the enrollment process for providers and suppliers.  42 U.S.C. §§ 1302, 1395cc(j).  A “supplier” includes “a physician or other practitioner, 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).  A supplier must enroll in the Medicare program to receive payment for covered items or services.  42 C.F.R. § 424.505.  To enroll, the supplier must submit an enrollment application and provide all required information.  42 C.F.R. § 424.510(a).

When CMS enrolls a physician or non-physician practitioner organization, CMS sets an effective date for billing privileges that is the later of the “date of filing” or the date the supplier began furnishing services at a new practice location.  42 C.F.R. § 424.520(d)(1),

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(2)(iii)-(iv).  The “date of filing” is the date that the CMS contractor receives an enrollment application that the contractor processes to approval.  73 Fed. Reg. 69,726, 69,769 (Nov. 19, 2008); Donald Dolce, M.D., DAB No. 2685 at 8 (2016).  When CMS assigns an effective date for a physician or non-physician practitioner organization, CMS may permit a retrospective billing period of up to 30 days, except in circumstances not applicable to this case.  42 C.F.R. § 424.521(a)(1)(i), (2)(iii)-(iv).

In this case, Petitioner primarily argues for an earlier effective date based on the time it took to obtain the information that the CMS contractor needed to enroll Petitioner.  CMS Ex. 9 at 2; Hr’g Req.  Petitioner also stated that CMS contractor personnel indicated that the enrollment effective date could be backdated.  CMS Ex. 9 at 3; Hr’g Req.

The effective date for a physician practice or non-physician practitioner practice in the Medicare program is the date that CMS receives an enrollment application that CMS processes to approval.  There are no exceptions to that rule.  The CMS contractor only processed Petitioner’s application received on June 4, 2025, to approval.  The CMS contractor formally rejected all of the previously filed enrollment applications; therefore, those applications cannot serve as a basis for an earlier effective date of enrollment.  Wishon Radiological Medical Group, Inc., DAB No. 2941 at 7 (2019).  The decision to reject an application is not subject to appeal; therefore, I cannot consider whether those applications were properly rejected.  42 C.F.R. § 424.525(d).  Finally, Petitioner alleges that CMS contractor personnel stated that Petitioner could obtain a backdated effective date.  However, that information was incorrect, and I am unable to provide an earlier effective date based on anything CMS contractor staff may have said.  See Fam. Health Servs. of Darke Cnty., Inc., DAB No. 2269 at 18-20 (2009).

The CMS contractor received an enrollment application from Petitioner on June 4, 2025, which the CMS contractor approved; therefore, June 4, 2025, is the effective date of Petitioner’s enrollment in the Medicare program.  42 C.F.R. § 424.520(d)(1)(i).  The CMS contractor provided Petitioner retrospective billing privileges from May 5, 2025, which is the most the CMS contractor could provide.  42 C.F.R. § 424.521(a)(1)(i).

VIII. Conclusion

The effective date for Petitioner’s enrollment in the Medicare program is June 4, 2025, with a retrospective billing period commencing on May 5, 2025.