Crosses Enterprises, LLC, DAB CR6865 (2026)

DECISION

Petitioner, Crosses Enterprises, LLC, is a supplier located in Indiana.  After the Medicare contractor deactivated Petitioner’s Medicare billing privileges, effective September 9, 2024, Petitioner submitted a new application, seeking to reactivate its enrollment. 

Acting on behalf of the Centers for Medicare & Medicaid Services (CMS), the Medicare contractor approved the application, with an effective billing date of March 12, 2025.  As a result, Petitioner’s Medicare coverage lapsed September 9, 2024 through March 11, 2025.  Here, Petitioner maintains that the deactivation was caused by a clerical mistake and fraud by its billing service and asks for an earlier effective date. 

On March 12, 2025, the Medicare contractor received Petitioner’s reactivation submission that it processed to approval.  March 12, 2025 is therefore the effective date for reactivating its billing privileges.  See 42 C.F.R. § 424.540(d)(2). 

I have no authority to review the deactivation nor to order retrospective reimbursement for services provided during the period of deactivation. 

Page 2

Background

In a notice letter dated April 2, 2025, the Medicare contractor, Wisconsin Physicians Solutions (WPS), advised Petitioner that the contractor approved its reactivation enrollment application with a gap in billing privileges from September 9, 2024 through March 11, 2025.  CMS Ex. 7. 

Petitioner requested reconsideration.  CMS Ex. 8.  In a reconsidered determination, dated August 31, 2025, a contractor hearing specialist affirmed the initial determination, with a gap in billing privileges from September 9, 2024 through March 11, 2025.  CMS Ex. 9. 

Petitioner appeals, and the matter is now before me. 

CMS moves for summary judgment.  However, because neither party requested to cross examine any of the proposed witnesses, an in-person hearing would serve no purpose.  See Acknowledgment and Pre-hearing Order at 9 ¶ 13 (May 6, 2025).  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 9 exhibits (CMS Exs. 1-9).  Petitioner filed a combined prehearing brief and response in opposition to the motion for summary judgment.  Petitioner also filed 16 exhibits (P. Exs. 1-16).  In the absence of any objections, I admit into evidence CMS Exs. 1-9 and Petitioner Exs. 1-16.  See Acknowledgment and Pre-hearing Order at 8 ¶ 10. 

Discussion

1. 1. On March 12, 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 § 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. 

Page 3

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 organization 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 “[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).  Because this case involves re-enrollment after a deactivation, additional regulations apply. 

Re-enrollment following deactivation.  The regulations governing re-enrollment after a deactivation differ in some 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) (emphasis added). 

Here, in a letter dated April 23, 2024, the contractor directed Petitioner to revalidate its Medicare enrollment records no later than July 31, 2024, and cautioned that Petitioner’s failing to respond may result in its Medicare billing privileges being deactivated.  CMS Ex. 1.  Petitioner did not file a response or revalidate its enrollment records. 

Page 4

In a notice letter, dated September 9, 2024, the contractor advised Petitioner that its Medicare billing privileges were being deactivated, effective September 9, 2024, pursuant to 42 C.F.R. § 424.540(a)(3) because the supplier had not fully and accurately responded to the contractor’s April 23, 2024 revalidation notification letter.  CMS Exs. 1, 2. 

Petitioner submitted a practice enrollment application on February 3, 2025.  CMS Ex. 3.  However, the contractor determined that the application was not complete and, in a development letter sent via email on February 24, 2025, it requested a voided check with the correct name matching IRS documents.  CMS Ex. 4  The letter warned that the enrollment application could be rejected if Petitioner did not furnish complete information by March 10, 2025.  CMS Ex. 4.  Petitioner did not, however, submit the additional information requested and the contractor rejected Petitioner’s application on March 10, 2025.  CMS Ex. 5. 

On March 12, 2025, the Medicare contractor received Petitioner’s reactivation submission that it processed to approval.  CMS Exs. 6, 7.  March 12, 2025 is therefore the effective date for reactivating its billing privileges.  See 42 C.F.R. § 424.540(d)(2). 

Petitioner argues that its billing privileges were deactivated because of errors outside of its control and because the billing service it utilized committed fraud.  P. Exs. 1-6.  However, I have no authority to review a deactivation.  Howard M. Sokoloff, DPM, MS, Inc., DAB No. 2972 at 6 (2019); Ark. Health Grp. d/b/a Baptist Health Family Clinic Lakewood, DAB No. 2929 at 7-9 (2019).  Next, Petitioner argues that CMS improperly rejected its application because Petitioner submitted the requested information.  P. Br. at 9.  However, I have no authority to review a rejected application either.  42 C.F.R. § 424.525(d); Wishon Radiological Med. Grp., Inc., DAB No. 2941 at 6-7 (2019); James Shepard, M.D., DAB No. 2793 at 8 (2017). 

Petitioner also argues that the only reactivation application it filed was on February 3, 2025.  P. Br. at 7.  However, the record does not support this contention.  Petitioner filed a CMS 855R on February 3, 2025 and a CMS 855R on March 12, 2025.  CMS Exs. 3, 6.  Petitioner additionally asserts that there is no proof that there was a CMS 855R filed on March 12, 2025 because both CMS 855R documents identified by CMS are identical.  P. Br. at 7.  However, the CMS 855R Petitioner filed on February 3, 2025 was rejected on March 10, 2025.  Compare CMS Ex. 3, with CMS Exs. 4 and 5 at 1-2.  The CMS 855R that was processed to approval is signed by Dr. Rafael Cruz and dated March 12, 2025.  CMS Ex. 6 at 1-2.  As a result, Petitioner’s argument is without merit. 

I also cannot direct the contractor to allow retrospective reimbursement.  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: 

Page 5

• 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 (2022). 

Conclusion

Because Petitioner filed its subsequently-approved reactivation application on March 12, 2025, March 12 is the earliest possible effective date.  See 42 C.F.R. § 424.540(d)(2).  

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).