City of Olivette Fire Department, DAB CR6864 (2026)

DECISION

Petitioner, City of Olivette Fire Department, challenges the Centers for Medicare and Medicaid Services’ (CMS’s) determination of its effective date of reactivation as a biller to the Medicare program following a period of deactivation due to its failure to revalidate.  As explained below, I find CMS properly determined April 22, 2025, as the reactivation effective date of Petitioner’s Medicare enrollment and billing privileges, as that is the date the Medicare administrative contractor received Petitioner’s reactivation application that was subsequently approved.

I. Background

On February 23, 2024, CMS contractor Wisconsin Physicians Service (WPS), advised Petitioner that it was obligated to revalidate its Medicare enrollment by May 31, 2024.  CMS Exhibit (Ex.) 1 at 1.  The letter informed Petitioner that it could resubmit its revalidation application either online through the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) or by mail.  Id.  The letter, which was mailed to Petitioner, further warned Petitioner that “[i]f we don’t receive your response by then, we may stop your Medicare billing privileges.”  Id.

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On July 24, 2024, WPS deactivated Petitioner’s Medicare billing privileges effective July 23, 2024.  CMS Ex. 2 at 1.  As the basis for the deactivation, WPS stated that Petitioner failed to timely revalidate its enrollment or that the application was rejected because Petitioner failed to respond to requests for more information.  Id. (citing 42 C.F.R. § 424.540(a)(3)).  WPS further advised Petitioner of its right to file a rebuttal if Petitioner believed the deactivation determination was incorrect.  Id. at 1-2 (citing 42 C.F.R. § 424.546).

On July 31, 2024, WPS received a revalidation application from Petitioner.  CMS Ex. 3.  WPS rejected this application on September 9, 2024, because the application did not include the practice location or confirmation of account information for form CMS 588–Electronic Funds Transfer (EFT) agreement.  CMS Ex. 4.  Petitioner submitted another revalidation application on October 23, 2024.  CMS Ex. 7.  This application was also rejected by WPS on December 2, 2024, due to incomplete information regarding form CMS 588. CMS Ex. 8.

On April 22, 2025, WPS received Petitioner’s third revalidation application.  CMS Ex. 9.  On May 29, 2025, WPS approved Petitioner’s application with an effective date of April 22, 2025.  CMS Ex. 10 at 1.  WPS also advised Petitioner that there would be a gap in billing privileges from July 23, 2024, through April 21, 2025.  Id.

Petitioner thereafter filed a request for reconsideration of the deactivation and the gap in billing privileges.  CMS Ex. 11.  On September 1, 2025, WPS issued a reconsidered determination and found no error in reactivating Petitioner’s Medicare billing privileges as of April 22, 2025, with a billing gap from July 23, 2024, through April 21, 2025.  CMS Ex. 11 at 1.

On October 30, 2025, Petitioner timely requested a hearing to dispute the reconsidered determination.  DAB E-File Doc. Nos. 1-1_a.  On November 5, 2025, I was designated to hear and decide this case and the Civil Remedies Division (CRD) acknowledged the hearing request and issued my Standing Pre-hearing Order (Standing Order).  Id. at Doc. Nos. 2-2_d.  Among other things, the Standing Order instructed the parties to file pre-hearing exchanges by specified dates.  Id. at 2_a.

On December 10, 2025, CMS filed a motion for summary judgment and pre-hearing brief (CMS Br.) and twelve proposed exhibits (CMS Exs. 1-12).  Id. at Doc. Nos. 5-6_g.  On September 17, 2025, I issued an Order to Show Cause after Petitioner failed to file a pre-hearing exchange by the deadline.  Id. at Doc. No. 7.  That same day, Petitioner filed a letter in response to the Order to Show Cause stating that its filings submitted on December 9, 2025, should be construed as its pre-hearing exchange.  Id. at Doc. No. 8.  I thereafter discharged the order to show cause as Petitioner had not abandoned the case.  Id. at Doc. No. 9.

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II. Admission of Exhibits and Decision on the Record

In the absence of objections, I admit CMS Exs. 1 through 12 into the record.

After filing its request for hearing, Petitioner submitted two proposed exhibits.  See DAB E-File Doc. Nos. 4_a-4_b.  I “must exclude ‘new documentary evidence’ – that is, documentary evidence that a provider did not previously submit to CMS at the reconsideration stage (or earlier) – unless [I] determine[] that ‘the provider or supplier has good cause for submitting the evidence for the first time at the ALJ level.’”  Care Pro Home Health, Inc., DAB No. 2723 at 11 (2016) (citing 42 C.F.R. § 498.56(e)(1)).  As the documents offered by Petitioner were either previously submitted to CMS during the proceedings below or are Petitioner’s characterization of the facts in the record before me and constitute argument, they are not new evidence.  As such Petitioner’s Exhibits A and B are admitted into the record.

The Standing Order advised the parties that an in-person hearing would only be necessary if a party submitted the written direct testimony of a proposed witness, and the opposing party requested an opportunity to cross-examine the witness.  Standing Order ¶¶ 11-13; see Vandalia Park, DAB No. 1940 (2004); Pac. Regency Arvin, DAB No. 1823 at 8 (2002) (holding that the use of written direct testimony for witnesses is permissible so long as the opposing party has the opportunity to cross-examine those witnesses).  Neither party has submitted any proposed witnesses.  As such, a hearing in this case is unnecessary, and I decide this case based on the written record.  CRDP §§ 16(b), 19(b), (d).  CMS’s motion for summary judgment is therefore moot.

III. Issue

Whether CMS had a legitimate basis to establish April 22, 2025, as the effective date of Petitioner’s reactivated Medicare billing privileges.

IV. Jurisdiction

I have jurisdiction to decide this case.  42 C.F.R. §§ 498.3(b)(15), 498.5(l)(2).

V. Findings of Fact, Conclusions of Law, and Analysis1

A. Applicable Law

1. Enrollment

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Petitioner participates in the Medicare program as a “supplier” of services.  Social Security Act (Act) § 1861(d); 42 C.F.R. § 498.2.  To receive Medicare payments for the services it furnishes to program beneficiaries, a prospective supplier must enroll in the program.  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.

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.  When CMS determines 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.  42 C.F.R. § 424.505.

The effective date for a supplier’s billing privileges “is the later of the date of filing” a subsequently approved enrollment application or “[t]he date that the . . . supplier first began furnishing services at a new practice location.”  42 C.F.R. § 424.520(d)(1) (emphasis added).  The “date of filing” is the date that the Medicare contractor “receives” a signed enrollment application that the Medicare contractor is able to process to approval.  73 Fed. Reg. 69, 726, 69,769 (Nov. 19, 2008); Donald Dulce, M.D., DAB No. 2685 at 7-8 (2016).  If a supplier satisfies certain requirements, CMS may allow a supplier to bill retrospectively for up to 30 days prior to the effective date.  42 C.F.R. § 424.521(a)(1).

2. Revalidation

To maintain billing privileges, a supplier must resubmit and recertify the accuracy of its enrollment information at least every five years, a process referred to as “revalidation.”  42 C.F.R. § 424.515.  Beyond these periodic revalidations, CMS may, at other times and for its own reasons, ask a supplier to recertify the accuracy of its enrollment information.  42 C.F.R. § 424.515(d).  Within 60 days of receiving CMS’s notice to recertify, the supplier must submit an appropriate enrollment application with complete and accurate information and supporting documentation.  42 C.F.R. § 424.515(a)(2).

3. Deactivation

The regulation authorizing deactivation explains that “deactivation [of Medicare billing privileges] is intended to protect the provider or supplier from the misuse of its billing number and to protect the Medicare Trust Funds from unnecessary overpayments.”  86 Fed. Reg. 62,240, 62,359 (Nov. 9, 2021).  CMS is authorized to deactivate an enrolled

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supplier’s Medicare billing privileges if the enrollee 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 recertify to the accuracy of its enrollment information.”  42 C.F.R. § 424.540(a)(3).  If CMS deactivates a supplier’s Medicare billing privileges, “[n]o payment may be made for otherwise Medicare covered items or services furnished to a Medicare beneficiary.”  42 C.F.R. § 424.555(b); see also 42 C.F.R. § 424.540(e).

4. Reactivation

The reactivation of an enrolled supplier’s billing privileges is governed by 42 C.F.R. § 424.540(b).  The process for reactivation is contingent on the reason for deactivation.  If CMS deactivates a supplier’s billing privileges due to a reason other than nonsubmission of a claim, the supplier must apply for CMS to reactivate its Medicare billing privileges by completing and submitting the appropriate enrollment application(s) or recertifying its enrollment information, if deemed appropriate.  42 C.F.R. § 424.540(a)(3), (b)(1); 71 Fed. Reg. 20,754, 20,762 (Apr. 21, 2006).  The effective date of a reactivation of billing privileges, following a period of deactivation, is the date on which the Medicare contractor received the supplier’s submission that was processed to approval.  42 C.F.R. § 424.540(d)(2).

B. Analysis

1. On April 22, 2025, WPS received Petitioner’s revalidation enrollment application that was processed to approval, which is the effective date of its Medicare reactivated enrollment.

As discussed above, the effective date of a reactivation of Medicare billing privileges is the date on which the Medicare contractor received the supplier’s submission that was subsequently processed to approval.  42 C.F.R. § 424.540(d)(2).

In this case, WPS received a revalidation enrollment application from Petitioner on April 22, 2025, and this application was processed to approval.  CMS Ex. 9 at 1, 12.  WPS thus appropriately found the effective date of Medicare billing privileges for Petitioner to be April 22, 2025, the date of receipt of the Medicare application that was subsequently approved by the contractor with a gap in billing privileges from July 23, 2024 through April 21, 2025.  CMS Ex. 10.

Although Petitioner clearly made several attempts to submit a revalidation application and provided responses to WPS’s requests for development, see CMS Exs. 3, 4, 5, 6, 7, 8, P. Ex. A, the earliest application in the record before me that WPS received and subsequently approved is the revalidation application it received on April 22, 2025.  CMS Exs. 9, 10.  Petitioner does not dispute the receipt date of this revalidation application.

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See P. Exs. A, B.  Nor does Petitioner point to an earlier application WPS received that it successfully processed to approval.  See P. Ex. B (Timeline).

Therefore, pursuant to 42 C.F.R. § 424.540(d)(2), the date WPS received Petitioner’s subsequently-approved enrollment application—April 22, 2025—is the correct reactivation effective date of enrollment.  Michael B. Zafrani, M.D., DAB No. 3075 at 2 n.1 (2022).

2. I have no authority to review the deactivation of Petitioner’s billing privileges and cannot afford it equitable relief.

In its Request for Hearing, Petitioner generally contents that WPS erred in deactivating its Medicare billing privileges, which resulted in a gap of billing privileges from July 23, 2024 through April 21, 2025.  See Request for Hearing.  Petitioner specifically states:

Olivette Fire Department experienced a lapse in Medicare enrollment from July 23, 2024, to April 21, 2025.  During this period, the Department worked directly with WPS to resolve the enrollment gap and provided all requested documentation within the required timeframe.  Despite this, WPS repeatedly indicated that the provider was “nonresponsive” — an inaccurate assessment, as all required responses had been submitted.

The issue stemmed from errors on the application processed by WPS.  Had WPS provided clear and concise feedback identifying the specific errors, Olivette Fire Department could have made the necessary corrections promptly, likely preventing the lapse in Medicare coverage.

Id.  While I acknowledge Petitioner’s argument, I have no authority to review WPS’s deactivation of Petitioner’s Medicare billing privileges.  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).  That is because it is only relevant whether WPS acted properly in deactivating Petitioner’s billing privileges.  Deactivation decisions in fact have an altogether separate review process that requires a provider or supplier dissatisfied with deactivation to file a rebuttal with CMS’s administrative contractor.  42 C.F.R. §§ 424.545(b), 424.546.  It is not clear from the record whether Petitioner sought relief from WPS through this rebuttal process.  However, my jurisdiction in this case is limited to reviewing the effective date of the approval of Petitioner’s reactivation enrollment application.  42 C.F.R. § 498.3(b)(15).

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Nor may I direct the contractor to allow retrospective reimbursement during the gap in billing privileges.  A supplier may not receive payment for services or items furnished while deactivated.  42 C.F.R. §§ 424.540(e), 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 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.

Lastly, I have no authority to review CMS’s revalidation process or otherwise grant Petitioner any form of equitable relief.  See, e.g., US Ultrasound, DAB No. 2302 at 8 (2010) (“Neither 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.”); Pepper Hill Nursing & Rehab. Ctr., LLC, DAB No. 2395 at 11 (2011) (holding that the ALJ and Board were not authorized to provide equitable relief by reimbursing or enrolling a supplier who does not meet statutory or regulatory requirements); UpturnCare Co., d/b/a Accessible Home Health Care, DAB No. 2632 at 19 (2015) (providing the Board may not overturn the denial of provider enrollment in Medicare on equitable grounds).  I am mindful and sympathetic to the fact that Petitioner has suffered a significant loss of income while rendering services to the Medicare program and made good-faith efforts to comply with revalidation requirements, however, I have no authority under the law to revise the effective date of reactivation determined by CMS.

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VI. Conclusion

I affirm CMS’s decision that the effective date of Petitioner’s Medicare enrollment and billing privileges is April 22, 2025.

I may not review the deactivation.

Retrospective reimbursement is not available for those whose enrollment has been deactivated.  42 C.F.R. § 424.540(e).