Life Care Primary Medical Associates, PLLC, DAB CR6872 (2026)

DECISION

Petitioner, Life Care Primary Medical Associates, PLLC, is a group medical practice, located in Sugarland, Texas, that participates in the Medicare program as a supplier of services.  After the Medicare contractor deactivated the practice’s Medicare billing privileges, 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 a reactivation effective date of December 3, 2025.  As a result, Petitioner’s billing privileges lapsed from November 1 through December 2, 2025. 

Petitioner challenges the contractor’s action and asks that its billing privileges be reinstated retroactively and that the billing gap be removed. 

Because Petitioner filed its subsequently-approved reactivation application on December 3, 2025, December 3 is the earliest possible effective date for its Medicare reactivation.  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.  

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Background

The Medicare contractor, Novitas Solutions, approved Petitioner’s reactivation enrollment application, effective December 3, 2025.  CMS Ex. 11.  In response, Petitioner requested reconsideration.  CMS Ex. 12.  In a reconsidered determination, dated January 5, 2026, a provider enrollment hearing specialist affirmed the December 3, 2025 effective date.  CMS Ex. 1. 

Petitioner appealed, and the matter is now before me.  

CMS moves for summary judgment.  However, because neither party proposes any witnesses, an in-person hearing would serve no purpose.  See Acknowledgment and Pre-Hearing Order at 4, 5, 6 (¶¶ 4(c)(iv), 8, 10) (January 8, 2026).  I may therefore decide this case based on the written record, without considering whether the standards for summary judgment are satisfied.  See CRD Procedures ¶ 19b.1 

Exhibits.  CMS submits its motion and brief (CMS Br.) with 12 exhibits (CMS Exs. 1-12).  In the absence of any objections, I admit into evidence CMS Exs. 1-12.  Although directed to do so, Petitioner did not file a brief or any other documents in response to CMS’s submissions.  Pre-Hearing Order at 3 (¶ 4).  In deciding this appeal, I consider the arguments made in Petitioner’s Request for Reconsideration (CMS Ex. 12) and its hearing request.  See Anil Hanuman, DAB No. 3080 at 12 (2022). 

In the absence of any objections, I admit into evidence CMS Exs. 1-12.  See Order at 5 (¶ 7).  

Discussion

1.  On December 3, 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).2 

Enrollment.  Petitioner participates in the Medicare program as a “supplier” of services.  See Social Security Act § 1861(d); 42 C.F.R. §§ 400.202; 498.2.  To receive Medicare

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payments for the services furnished to program beneficiaries, a supplier must enroll in the program.  Act §§ 1835(a); 1842(h)(1); 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 (Defining “enrollment”).  

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 (Defining “enrollment application).3   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 practice 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 “the date that the supplier first began furnishing services at a new practice location.”  42 C.F.R. § 424.520(d) (Emphasis added).  

Deactivation and reactivation.  The regulations governing reactivation differ in significant ways from the enrollment regulations.  See 86 Fed. Reg. 62,240, 62,359-60 (Nov. 9, 2021). 

“Deactivate” means that a supplier’s billing privileges are stopped but can be restored when it submits updated information.  42 C.F.R. § 424.502 (Defining “deactivate”).  When a supplier’s billing privileges are deactivated, no payment is made for otherwise Medicare-covered services furnished to beneficiaries.  42 C.F.R. § 424.55(b).  If the supplier furnishes those services while deactivated, the expenses incurred are the supplier’s responsibility.  42 C.F.R. § 424.555(c). 

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). 

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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). 

CMS may reject a supplier’s enrollment application if the “supplier fails to furnish complete information on the . . . enrollment application within 30 days from the date the contractor requested the missing information.  42 C.F.R. § 424.525(a)(1).  Tosan Fregene, M.D. and Oncology Clinics, Inc., DAB No. 3018 at 2 (2020). 

Petitioner’s deactivation and reactivation.  Here, in a letter dated July 31, 2025, the contractor directed Petitioner to revalidate its Medicare enrollment records no later than October 1, 2025, and cautioned that if the practice failed to respond, the contractor could stop its Medicare billing privileges.  CMS Ex. 3.  Petitioner did not respond.  

In a follow-up letter, dated November 2, 2025, the contractor advised Petitioner that it was “placing a stay” on its Medicare enrollment, effective November 2, 2025, because the practice did not respond to the contractor’s revalidation request.  CMS Ex. 4.  The letter warned that the “[f]ailure to submit a revalidation application within 30 days of this notice may result in a deactivation of your Medicare enrollment.”  Id. (Emphasis added).  The letter also explained that the practice could resume receiving payments if it revalidated its Medicare enrollment.  Id.  Again, Petitioner did not respond. 

In a letter dated December 3, 2025, the contractor advised Petitioner that, pursuant to 42 C.F.R. § 424.530(a)(3), its Medicare billing privileges were deactivated, effective November 2, 2025, because it hadn’t timely revalidated its enrollment record.  The contractor would not pay any Medicare claims after that date.  CMS Ex. 7. 

On December 3, 2025, Petitioner submitted a new enrollment application, which the contractor processed to approval.  CMS Ex. 8.  December 3 is therefore the effective date for reactivating Petitioner’s billing privileges.  See 42 C.F.R. § 424.540(d)(2). 

Petitioner concedes that the practice “inadvertently overlooked” the contractor’s revalidation request and failed to respond promptly but asked for retroactive reinstatement.  CMS Ex. 12 at 3.  Petitioner also maintains that he had been seeing patients “in good faith,” with no complaints.  Hearing Request. 

I have no authority to review a deactivation.  Jeffrey E. McIlroy, MD, Inc., DAB No. 3143 at 3-4 (2024); Tosan Fregene, MD and Oncology Clinics, Inc., DAB No. 3918 at 3 (2020); see 42 C.F.R. § 498.3(b) (defining “initial determinations” that are subject to review by an ALJ and the Departmental Appeals Board).  

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Nor may I grant Petitioner an earlier effective date based on any equitable or policy arguments.  Howard M. Sokoloff, DPM, MS, Inc., DAB No. 2972 at 6, 9 (2019); Wishon Radiological Med. Grp., Inc., DAB No. 2941 at 6-7 (2019); Ark. Health Grp., DAB No. 2929 at 7-9 (2019); James Shepard, M.D., DAB No. 2793 at 8 (2017).  

Finally, I may not 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), 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, 62420-21 (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 December 3, 2025, December 3 is the earliest possible effective date for its reactivation.  See 42 C.F.R. § 424.540(d)(2).  

I may not review the contractor’s deactivation, and retrospective reimbursement is not available for those whose enrollment has been deactivated.  42 C.F.R. § 424.540(e).