Prime Healthcare Illinois Medical Group LLC, DAB, CR6897 (2026)

DECISION

Petitioner, Prime Healthcare Illinois Medical Group LLC, is a supplier practicing in Illinois.  Petitioner applied to enroll in the Medicare program and reassign one of its provider’s billing privileges.  The Centers for Medicare & Medicaid Services (CMS) granted its application with a retrospective billing date of April 5, 2025 and an effective date of June 4, 2025.  Petitioner now challenges that effective date. 

Because Petitioner filed its subsequently-approved enrollment application on June 4, 2025, I find that June 4 is the correct effective date of its enrollment.  Howard M. Sokoloff, DPM, MS, Inc., DAB No. 2972 (2019); Urology Grp. of NJ, LLC, DAB No. 2860 (2018); Willie Goffney, Jr., M.D., DAB No. 2763 at 7 (2017), aff’d sub nom. Goffney v. Azar, No. CV 17-8032 MRW (C.D. Cal. Sept. 25, 2019). 

Background

In a letter dated June 10, 2025, the Medicare contractor, National Government Services (NGS), advised Petitioner that it approved Petitioner’s Medicare enrollment with an “effective date” of April 5, 2025.  CMS Ex. 5.  In fact, as explained below, the contractor

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was granting Petitioner a billing date of April 5, 2025; the effective date of Petitioner’s enrollment was June 4, 2025 (see discussion below).  Petitioner sought reconsideration, asking that the effective date of his enrollment be changed to March 1, 2025.  CMS Ex. 6.  In a reconsidered determination, dated September 26, 2025, the contractor denied Petitioner an earlier effective date, concluding that June 4 was the correct effective date, with a retrospective billing date of April 5, 2025.  CMS Ex. 7. 

Petitioner appealed. 

Although CMS has moved for summary judgment, I find that this matter may be decided on the written record, without considering whether the standards for summary judgment are satisfied.  In his initial order,1  the Administrative Law Judge instructed the parties to list their proposed witnesses (if any) and to submit written direct testimony for each witness.  Standing Order at 9 (November 20, 2024).  I also directed each party to state, affirmatively, whether it intended to cross-examine any proposed witness.  Order at 9.    An in-person hearing is necessary “only if a party files admissible, written direct testimony, and the opposing party asks to cross-examine.”  Order at 9.  CMS lists no witnesses.  For his part, Petitioner lists one witness, Christopher Doan, and proffers his written testimony.  CMS has not asked to cross-examine Petitioner’s witness.  An in-person hearing would therefore serve no purpose, and I may decide the case based on the written record. 

With its motion and brief, CMS submits 7 exhibits (CMS Exs. 1-7).  Petitioner submits 13 exhibits.  Petitioner objects to CMS Ex. 4 on the grounds that it lacks authentication, foundation and violates hearsay rules.  However, ALJs are not bound by the Federal Rules of Evidence and may receive evidence that may otherwise be inadmissible.  42 C.F.R. § 498.61.  I will admit CMS Ex. 4 and find that Petitioner’s objections will go to the weight afforded the evidence.  I will also admit the remainder of CMS’s exhibits. 

CMS does not object to Petitioner’s exhibits.  However, Petitioner admits that the majority of its exhibits were not submitted at the time of the request for reconsideration and further admits that the evidence was available at the time of the request.  I am required to examine any new documentary evidence to determine whether the provider has good cause for submitting it for the first time at the ALJ level of review.  If I find that good cause does not exist, I must exclude the evidence and may not consider it in reaching a decision.  42 C.F.R. § 498.56(e), see 42 C.F.R. § 405.803(e).  Petitioner was, or should have been, aware of this requirement.  The language regarding the submission of evidence was plainly laid out in the June 10, 2025 notice letter. 

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Petitioner asserts that it is providing this evidence for the first time because it was unaware of the arguments CMS would be raising in its brief.  Petitioner asserts that it was not aware that CMS would be arguing that its original application was rejected until it received the reconsidered determination.  Petitioner was sent a rejection letter on April 15, 2025.  However, the evidence does show that there was some genuine confusion over the status of Petitioner’s applications.  As a result, I find that good cause exists and admit Petitioner’s exhibits into evidence. 

Discussion

1. Petitioner filed its subsequently-approved applications on June 4, 2025, and its Medicare enrollment can be no earlier than that date.  42 C.F.R. § 424.520(d).2 

Enrollment.  Petitioner participates in the Medicare program as a “supplier” of services.  Social Security 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. § 424.502.3   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.  The effective date for its 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) (emphasis added). 

If a supplier meets all program requirements, CMS may allow it to bill retrospectively for up to 30 days prior to the effective date “if circumstances precluded enrollment in advance of providing services to Medicare beneficiaries . . . .”  42 C.F.R. § 424.521(a)(1). 

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An additional 30 days may be granted pursuant to 42 C.F.R. § 424.522(a) when reassignment of billing privileges is involved. 

Some Medicare contractors have created confusion because they are inclined to conflate the effective date with the retrospective billing date, as the contractor did in this case.  The distinction is important; I have the authority to review “[t]he effective date of . . . supplier approval.”  42 C.F.R. § 498.3(b)(15).  But nothing in the regulations gives me the authority to review CMS’s determinations regarding retrospective billing. 

Here, on June 4, 2025, the Medicare contractor received Petitioner’s enrollment applications (CMS 855B and CMS 855R), which the contractor subsequently approved.  CMS Ex. 5.4   Thus, pursuant to section 424.520(d), the date Petitioner filed his subsequently-approved enrollment applications – June 4, 2025 – is the correct effective date of enrollment.  Sokoloff, DAB No. 2972 at 6-7; Urology Grp., DAB No. 2860 at 7-9; Goffney, DAB No. 2763 at 7.  

Petitioner, however, complains that it began providing covered services more than a month prior to the retrospective billing date.  Petitioner points out – and CMS agrees – that Petitioner submitted an initial application on March 7, 2025.  CMS Ex. 1.  However, claiming that Petitioner did not timely respond to the contractor’s requests for additional submissions, the contractor rejected those applications.  CMS Ex. 3.  Petitioner argues that it, in fact, timely responded to the requests and that the contractor should not have rejected the March 7 applications.  P. Br. at 4-6; P. Exs. 8, 9.  However, I have no authority to review the rejection of an enrollment application.  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).  And the evidence shows that the March 7, 2025 application was rejected on April 15, 2025.  CMS Ex. 3. 

Petitioner additionally argues that it did not submit an application on June 4, 2025.  However, the June 4, 2025 applications are dated and signed by Petitioner’s authorizing officials.  CMS Ex. 4.  Petitioner does not present any evidence to the contrary.  Petitioner also argues that it submitted an application on April 15, 2025 but does not provide proof of an application.  

I agree with Petitioner that CMS and its contractor provided confusing information to Petitioner.  However, short of a finding of affirmative misconduct on the part of the contractor, I cannot overturn NGS’s effective date.  See, e.g., Richard Weinberger, M.D. & Barbara Vizy, M.D., DAB No. 2823 at 19 (2017) (citing Office of Personnel Management v. Richmond, 496 U.S. 414, 419-21 (1990)).  As the appellate panel in

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Weinberger & Vizy emphasized, “affirmative misconduct appears to require something more than failing to provide accurate information or negligently giving wrong advice.”  DAB No. 2823 at 19 (internal quotation marks and citations omitted).  The contractor may have provided information to Petitioner that led to confusion over the status of its applications, but its behavior does not rise to the level of affirmative misconduct.  Petitioner makes similar arguments with regard to the Department of Government Efficiency but does not make a showing that affirmative misconduct occurred in the processing of its applications.  

To the extent Petitioner is arguing that there were issues with its applications due to website issues or other concerns because of the time its March application was submitted, I cannot grant equitable relief.  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.  US Ultrasound, DAB No. 2302, (2010). 

Conclusion

Because Petitioner filed its subsequently-approved enrollment application on June 4, 2025, CMS properly granted Petitioner Medicare enrollment effective that date.