Community Ambulance Service for Northern Des Moines County, DAB CR6907 (2026)

DECISION

Wisconsin Physicians Service Insurance Corporation (WPS), a Medicare administrative contractor for the Centers for Medicare & Medicaid Services (CMS), approved the enrollment application of Community Ambulance Service for Northern Des Moines County (Petitioner) effective March 31, 2025, a date which was also upheld in a reconsidered determination.  Petitioner requests a hearing before an administrative law judge (ALJ) because it does not want a gap in its billing privileges from November 8, 2024, through March 30, 2025.

My jurisdiction in this matter is limited to determining whether WPS assigned the correct date for reactivation under the law.  I do not have jurisdiction to review WPS’s decision to deactivate Petitioner’s billing privileges or to issue equitable relief.  As to the issue before me, I affirm WPS’s determination that Petitioner’s effective date for reactivation of Medicare billing privileges is March 31, 2025, because that is the date WPS received Petitioner’s reactivation application that it processed to approval.

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I.  Background

A.  Procedural History

On November 25, 2025, WPS issued a reconsidered determination, finding that March 31, 2025, was the effective date of reactivation of Petitioner’s Medicare billing privileges.  On January 23, 2026, Petitioner timely filed a request for hearing (RFH) to dispute the reconsidered determination.  Petitioner’s request was initially assigned to Administrative Law Judge (ALJ) Benjamin Zeitlin and, on January 29, 2026, the Civil Remedies Division acknowledged the hearing request and issued ALJ Zeitlin’s Standing Prehearing Order (Prehearing Order).1 

On March 5, 2026, CMS timely filed a prehearing exchange, which included a Motion for Summary Judgment, Memorandum in Support of Motion for Summary Judgment and Respondent’s Brief (CMS Br.), and 12 proposed exhibits (CMS Exs. 1-12).  On April 9, 2026, Petitioner timely filed its exchange, which included a Resistance to CMS’s Motion for Summary Judgment (Response), Petitioner’s Memorandum of Authorities in Opposition to Respondent’s Motion for Summary Judgment and Petitioner’s Brief (P. Br.), and four proposed exhibits, including the affidavit of one proposed witness (P. Exs. 1-4). 

Petitioner did not object to any of CMS’s proposed exhibits.  Therefore, CMS exhibits 1 through 12 are admitted into the record.  Prehearing Order ¶ 10; Civ. Remedies Div. P. § 14(e).  Petitioner also submitted proposed exhibits, including new documentary evidence.  Petitioner’s exhibit 1 is a log of written correspondence received from or sent to WPS regarding Petitioner’s revalidation application.  Petitioner offers this exhibit in response to WPS’s assertion in its reconsidered determination that it sent Petitioner a development letter on October 9, 2024, an assertion Petitioner states it learned of for the first time upon receiving the reconsidered determination.  RFH at 2.  Based on these representations, I find good cause to admit the newly submitted evidence. 42 C.F.R. § 498.56(e)(2)(i).  Petitioner’s exhibits 2 and 3 are not new evidence; they duplicate previously submitted documents.  Exhibit 4 is the affidavit of Petitioner’s witness.  For these reasons, and in the absence of any objection from CMS, I admit Petitioner’s exhibits 1 through 4 into the record. 

Because CMS has not requested to cross-examine Petitioner’s proposed witness, a hearing is not necessary.  Prehearing Order ¶ 13.  I decide this case on the written record, meaning the parties’ written submissions and arguments, and without considering

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whether the standard for summary judgment is met.  Id.; Civ. Remedies Div. P. § 19(d).  I deny CMS’s summary judgment motion as moot. 

II.  Issue

Whether WPS, acting on CMS’s behalf, had a legitimate basis to assign March 31, 2025, as the effective date for the reactivation of Petitioner’s Medicare billing privileges. 

III.  Jurisdiction

I have jurisdiction to hear and decide this case.  42 C.F.R §§ 498.3(b)(15), 498.5(l)(2); see also 42 U.S.C. § 1395cc(j)(8). 

IV.  Findings of Fact

1. Petitioner is an ambulance service supplier located in Iowa.  Its NPI is 1932277795, and PTAN is 18084.  CMS Ex. 1; CMS Ex. 2 at 11.
2. On July 30, 2024, WPS mailed a revalidation letter to Petitioner informing Petitioner that it was required to revalidate its Medicare enrollment record by October 31, 2024.  CMS Ex. 1.  The notice warned that CMS could deactivate Petitioner’s enrollment if it did not timely respond.  Id. at 1.
3. On August 15, 2024, WPS notified Petitioner that it was out of compliance with Medicare regulations, and that it needed to update its enrollment application due to the death of a listed delegated official, managing employee and director/officer.  CMS Ex. 2 at 50-53.  The notice warned that CMS could deactivate Petitioner’s enrollment if it failed to comply within 90 calendar days.  Id.
4. Petitioner submitted a Medicare Enrollment Application, and supporting documents in response to WPS’s July 30, 2024 and August 15, 2024 notices, postmarked September 12, 2024, and received on September 16, 2024.  CMS Ex. 2; see also id. at 50-54, 74.
5. On October 9, 2024, WPS notified Petitioner that it received its enrollment application but that its application required revisions and supporting documentation.  CMS Ex. 3.  The notice letter stated that “[f]ailure to submit a complete revalidation enrollment application(s) and all supporting documentation within 30 days will result in deactivation of your Medicare billing privileges.”  Id. at 1.
6. By notice dated November 12, 2024, WPS notified Petitioner that its September 16, 2024 application was rejected for multiple reasons and that if Petitioner would like to resubmit, it would have to complete a new Medicare enrollment application.  CMS Ex. 4 at 1-2.  The notice stated, “[i]n compliance with Federal regulations found at

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42 CFR § 424.525, providers and suppliers are required to submit complete applications and all supporting documents within 30 calendar days from the postmark date of the contractor request for missing/incomplete information.  Id. at 2; see also P. Ex. 2. 

7. By separate notice, also dated November 12, 2024, WPS notified Petitioner that its billing privileges were being deactivated effective November 8, 2024 because it did not timely revalidate its enrollment record, or its revalidation application had been rejected because Petitioner did not timely respond to WPS’s requests for more information.  CMS Ex. 5.  The notice instructed that if Petitioner believed the deactivation determination was incorrect, it could submit a rebuttal.  Id. at 1-2.
8. On January 31, 2025, Petitioner submitted an enrollment application stating that its previously submitted application was rejected and that its earlier resubmission was never processed.  CMS Ex. 6 at 3; id. at 83 (postmarked February 3, 2025).  Petitioner included in its submission a cover letter dated November 22, 2024, stating that its earlier application was rejected and with a handwritten note, “WPS Never Received[.]”  Id. at 4.
9. On February 26, 2025, WPS sent a notice to Petitioner explaining it received its enrollment application but it required revisions and supporting documentation.  CMS Ex. 7.  The notice stated that its application could be rejected if it did not furnish the complete information within 30 calendar days.  Id. at 1.  The notice also instructed Petitioner to submit the requested revisions and supporting documents within 14 days of the postmark, and provided the addresses for regular mail and overnight mail.  Id. at 2.
10. On March 28, 2025, WPS issued a notice letter stating that it was rejecting its enrollment application received on February 6, 2025, for multiple reasons.  CMS Ex. 8 at 1-2.
11. Petitioner submitted another enrollment application, postmarked March 27, 2025, which was received on March 31, 2025.  CMS Ex. 9 at 110.
12. On July 3, 2025, WPS issued a notice of initial determination in which it approved Petitioner’s reactivation enrollment application.  CMS Ex. 10.  The notice identified a gap in billing privileges “from November 08, 2024 through March 30, 2025.”  Id. at 1.
13. By request dated September 2, 2025, Petitioner filed a reconsideration request.  CMS Ex. 11.  Among other things, Petitioner explained that it timely responded to WPS’s November 12, 2024 correspondence.  Id. at 1-2.  Petitioner stated that correspondence was not received by WPS and it resubmitted the supplemental information on January

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31, 2025.  Id. at 2.  Petitioner also stated that it received multiple requests for supplemental information, all of which were timely responded to.  Id. at 2.

14. On November 25, 2025, WPS issued an unfavorable reconsidered determination.  CMS Ex. 12.  WPS explained that Petitioner’s enrollment was correctly deactivated effective November 8, 2024, due to a failure to fully revalidate.  Id. at 2-3.  WPS affirmed the effective date of reactivation, March 31, 2025, explaining that was the date of receipt of the application that was processed to approval.  Id. at 3.  Finally, WPS stated it was unable to remove the gap in billing privileges from November 8, 2024, to Mach 30, 2025.  Id.

V.  Conclusions of Law

1. Based on the reactivation enrollment application that WPS approved in this case, the effective date for reactivation of Medicare billing privileges is the date the approved application was received by WPS, i.e., March 31, 2025.  42 C.F.R. § 424.540(d)(2).

VI.  Analysis

The Social Security Act (Act) authorizes the Secretary to promulgate regulations governing the enrollment process for providers and suppliers.  42 U.S.C. §§ 1302, 1395cc(j).  Pertinent here, a “supplier” is “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); see also 42 U.S.C. § 1395x(u). 

A supplier must enroll in the Medicare program to receive payment for covered Medicare items or services.  42 C.F.R. § 424.505.  The term “Enroll/Enrollment means the process that Medicare uses to establish eligibility to submit claims for Medicare-covered items and services, and the process that Medicare uses to establish eligibility to order or certify Medicare-covered items and services.”  42 C.F.R. § 424.502.  A supplier seeking Medicare billing privileges must “submit enrollment information on the applicable enrollment application.”  42 C.F.R. § 424.510(a)(1). 

To maintain Medicare billing privileges, suppliers must revalidate their enrollment information at least every five years.  42 C.F.R. § 424.515.  However, CMS reserves the right to perform revalidations at any time.  42 C.F.R. § 424.515(d), (e).  When CMS notifies providers and suppliers that it is time to revalidate, the providers or suppliers must submit the appropriate enrollment application, accurate information, and supporting documentation within 60 calendar days of CMS’s notification.  42 C.F.R. § 424.515(a)(2).  CMS may also reject an enrollment application if the supplier does not furnish complete information within 30 days of a contractor’s request or fails to provide required documentation within 30 days of submission.  42 C.F.R. § 424.525(a)(1)–(2). 

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After a rejection, the supplier must submit a new enrollment application with all required documentation. 42 C.F.R. § 424.525(c). 

Finally, CMS can deactivate an enrolled supplier’s Medicare billing privileges if the enrollee fails to comply with revalidation requirements.  42 C.F.R. § 424.540(a)(3).  When CMS deactivates 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). 

In this case, WPS issued a notice letter dated November 12, 2024, deactivating Petitioner’s billing privileges after rejecting its September 2024 application for failing to timely respond to its request for additional information.  CMS Ex. 5; see also CMS Ex. 4.  I acknowledge, and have no basis to doubt, Petitioner’s assertion that it did not receive the October 9, 2024 development letter.  I also recognize Petitioner’s argument that, if it did not receive the letter, it could not be found noncompliant for failing to respond; however, Petitioner cites no legal authority permitting administrative review of CMS’s decision to deactivate or reject an enrollment application, and I am aware of none.  To the contrary, the regulations are clear that I do not have authority to review CMS’s decision to deactivate because deactivation is not an initial determination subject to appeal.  42 C.F.R. §§ 424.545(b) (providing rebuttal rights pursuant to § 424.546) and 498.3(b); see also Urology Group of New Jersey, LLC, DAB No. 2860 at 6 (2018).  Similarly, “[e]nrollment applications that are rejected are not afforded appeal rights.”  42 C.F.R. § 424.525(d). 

Turning to the action within my authority, the reactivation date, I find no error in WPS’s determination.  If CMS deactivates a supplier’s billing privileges due to an untimely or incomplete response to a revalidation request, the enrolled supplier may apply for CMS to reactivate its Medicare billing privileges by recertifying its enrollment information that is on file or, if deemed appropriate by CMS, complete a new enrollment application.  42 C.F.R. § 424.540(b)(1), (2).  The effective date of reactivation is the date on which the Medicare contractor received the supplier’s reactivation submission that was processed to approval.  42 C.F.R. § 424.540(d)(2). 

The record reflects that Petitioner submitted multiple applications following its deactivation: November 22, 2024 (not received by WPS); January 31, 2025 (received February 6, 2025); and March 27, 2025 (received March 31, 2025).  CMS Ex. 6 at 3–4; CMS Ex. 9.  Petitioner states it mailed a response to the November 12, 2024 notice rejecting its application on November 22, 2024, but WPS did not receive it; therefore, it resubmitted its application on January 31, 2025, received February 6, 2025.  However, that application was incomplete and WPS issued a development letter on February 26, 2025.  CMS Ex. 7.  Petitioner responded to the development letter with a submission postmarked March 27, 2025.  CMS Ex. 9 at 68.  However, before it received this

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submission, WPS issued a rejection letter on March 28, 2025.2  CMS Ex. 8.  Consequently, WPS treated the March 2025 submission as a new application.  CMS Ex. 9.  The application WPS received on March 31, 2025, was processed to approval.  CMS Ex. 10.  Accordingly, the effective date of reactivation is March 31, 2025.  42 C.F.R. § 424.540(d)(2). 

I recognize Petitioner does not want a gap in its Medicare billing privileges.  Petitioner maintains that the antecedent question—whether the deactivation was proper—remains unresolved.  But as explained, that issue is outside my jurisdiction.  I further acknowledge that delays in WPS’s receipt of Petitioner’s paper submissions appear to have contributed to some of the difficulties in meeting the contractor’s development deadlines.  Nonetheless, the reactivation regulation does not permit retrospective billing privileges under any circumstances.  42 C.F.R. § 424.540(e).  To the extent Petitioner seeks equitable relief, I am not authorized to grant it.  An ALJ may not provide equitable relief by reimbursing or enrolling a supplier that does not meet statutory or regulatory requirements.  US Ultrasound, DAB No. 2302 at 8 (2010). 

VII.  Conclusion

For the reasons explained above, the reactivation effective date for Petitioner’s Medicare billing privileges is March 31, 2025.