Reno Neurological Associates, DAB CR6932 (2026)

DECISION

I affirm the determination of the Centers for Medicare & Medicaid Services (CMS) that the effective date for the reactivation of Petitioner’s Medicare billing privileges is November 26, 2025. 

I.  Procedural History

On March 26, 2026, Petitioner requested a hearing to dispute the effective date for the reactivation of its Medicare billing privileges.  On March 27, 2026, the Civil Remedies Division acknowledged the hearing request, provided a prehearing submission schedule to the parties, and issued my Standing Order.  On May 1, 2026, CMS filed a prehearing exchange, which included 11 proposed exhibits.  Petitioner did not file a prehearing exchange.1   However, Petitioner’s request for hearing included multiple documents and arguments.  As a result, I will accept Petitioner’s initial filing as its arguments and exhibits. 

II.  Admission of Evidence

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Absent objection, I admit all of the proposed exhibits into the record.  See Standing Order ¶ 10; Civil Remedies Division Procedures (CRDP) § 14(e). 

III.  Decision on the Written Record

I directed the parties to submit written direct testimony for any witnesses they wanted to offer.  Standing Order ¶ 11.  I also informed the parties as follows: 

If the parties either do not file any written direct testimony or the parties do not request to cross-examine any of the witnesses from whom written direct testimony has been submitted, I will consider such actions by the parties to serve as a constructive request for a decision on the written record because there will be no reason to hold an in-person hearing. 

Standing Order ¶ 7(g)(iii); see also CRDP §§ 16(b), 19(b), (d).  I further advised:  “Unless a hearing is required for cross-examination of a witness or witnesses, the record will be closed and the case will be ready for a decision after all the submission deadlines have passed.”  Standing Order ¶ 14. 

Neither party submitted written direct testimony.  Therefore, I decide this case on the written record.  Anil Hanuman, D.O., DAB No. 3080 at 11-12 (2022). 

IV.  Issue

Whether November 26, 2025, is the correct effective date for the reactivation of Petitioner’s Medicare billing privileges. 

V.  Jurisdiction

I have jurisdiction to decide the issue in this case.  42 C.F.R. § 498.3(b)(15). 

VI.  Findings of Fact

1. Petitioner is a medical practice who was enrolled in the Medicare program.  See CMS Ex. 1.
2. In a June 11, 2025 notice, a CMS contractor requested Petitioner revalidate its enrollment within 90 days.  CMS Ex. 1.  The notice informed Petitioner that failure to respond would result in deactivation of Petitioner’s enrollment.  Id.
3. The CMS contractor sent a letter dated September 11, 2025, deactivating

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Petitioner’s Medicare billing privileges on September 10, 2025 for failing to respond to the June 11, 2025 revalidation request.  CMS Ex. 2.

4. On September 12, 2025, the CMS contractor received a CMS reactivation application from Petitioner.  CMS Ex. 3.  On October 10, 2025, the contractor requested additional information from Petitioner that was required to process its application.  CMS Ex. 4.  Petitioner was informed that it had 30 days to respond or its application could be rejected.  Id.  Petitioner responded to the request for additional information on October 16 and 21, 2025.  CMS Exs. 5, 6.
5. On November 11, 2025, the contractor rejected Petitioner’s September 12, 2025 application for failure to provided the requested additional information.  CMS Ex. 7.
6. On November 26, 2025, Petitioner submitted a new application for reactivation.  CMS Ex. 8.
7. In a January 15, 2026 notice, the CMS contractor approved Petitioner’s application for the reactivation of Medicare billing privileges, effective November 26, 2025.  CMS Ex. 9.  This resulted in Petitioner having a billing gap from September 10, 2025 through November 25, 2025.  Id.; CMS Ex. 2.
8. On January 29, 2026, Petitioner requested reconsideration of the effective date for reactivation.  CMS Ex. 10.
9. In a March 30, 2026 reconsidered determination, the CMS contractor upheld the November 26, 2025 effective date of reactivation.  CMS Ex. 11. 

VII.  Conclusions of Law and Analysis

1. The effective date of reactivation for Petitioner’s Medicare billing privileges is November 26, 2025, because CMS received Petitioner’s reactivation enrollment application on November 26, 2025, and a CMS contractor was able to process that application to approval. 

The Social Security Act (Act) authorizes the Secretary of Health and Human Services (Secretary) to promulgate regulations governing the enrollment process for providers and suppliers.  42 U.S.C. §§ 1302, 1395cc(j).  A “Supplier” for Medicare program purposes includes “Physical therapists in private practice.  42 C.F.R. § 424.502; see also 42 U.S.C. § 1395x(d), (p); 42 C.F.R. § 410.60(a)(3)(ii), (c).  A supplier must enroll in the Medicare program to receive payment for covered items or services.  42 U.S.C. §§ 1395n(a), 1395u(h)(1); 42 C.F.R. § 424.505.  To enroll, the supplier must submit an enrollment

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application and provide all required information.  42 C.F.R. § 424.510(a).  To maintain enrollment, a supplier must recertify the accuracy of its enrollment information every five years.  42 C.F.R. § 424.515.  To do this, a supplier “must submit to CMS the applicable enrollment application with complete and accurate information and applicable supporting documentation within 60 calendar days of [CMS’s] notification to resubmit and certify to the accuracy of its enrollment information.”  42 C.F.R. § 424.515(a)(2). 

To reactivate billing privileges, the supplier must recertify that its reenrollment information currently on file with CMS is correct and furnish any missing information.  42 C.F.R. § 424.540(b)(1).  Further, CMS may, for any reason, require a deactivated supplier file a CMS-855 enrollment application to reactive billing privileges.  42 C.F.R. § 424.540(b)(2).  When a supplier seeks reactivation, “[t]he effective date of a reactivation of billing privileges under this section is the date on which the Medicare contractor received the . . . supplier’s reactivation submission that was processed to approval by the Medicare contractor.”  42 C.F.R. § 424.540(d)(2).  CMS may not pay a supplier for any health care items or services provided during the period of deactivation.  42 C.F.R. §§ 424.540(e), 424.555(b); 86 Fed. Reg. 62,240, 62,359-60 (Nov. 9, 2021); see also Goffney v. Becerra, 995 F.3d 737, 743 (9th Cir. 2021). 

Petitioner requests that the gap in billing privileges be removed because it continued to treat patients during that time period and that it will suffer a large loss of money.  Petitioner additionally asserts that nothing has changed with its practice except for the death of one of its doctors six years after he stopped practicing.  Petitioner also asserts that it had problems accessing PECOS and had to mail documents.  And, that some of those documents were mailed to an incorrect address that had been provided by the contractor. 

However, I am unable to modify the effective date for reactivation.  As stated above, the standard for setting the effective date for reactivation is the date that CMS receives the reactivation application when that application is processed to approval.  42 C.F.R. § 424.540(d)(2).  In this case, the effective date of reactivation is November 26, 2025, because that is the date that the reactivation application was received, and that application was processed to approval. 

I understand Petitioner’s argument that little information had changed in its reactivation application and that it relied on mail because of access issues with PECOS.  However, my jurisdiction is limited to determining whether CMS assigned Petitioner the correct date of reactivation.  See 42 C.F.R. § 498.3(b)(15) (effective date for supplier approval is an appealable initial determination).  I do not have jurisdiction to review CMS’s decision to deactivate Petitioner’s Medicare billing privileges.  See 42 C.F.R. §§ 424.545(b), 424.546(f) (CMS has the sole authority to consider any rebuttal to the deactivation filed by a supplier); Michael B. Zafrani, M.D., DAB No. 3075 at 3, 8 (2022).

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Ultimately, I am sympathetic to Petitioner’s situation and the frustrations it must have encountered with its experience accessing PECOS.  However, I cannot ignore regulations that the Secretary has promulgated.  The regulations require a reactivation effective date of November 26, 2025.  42 C.F.R. § 424.540(d)(2).  Further, I cannot direct CMS to pay Petitioner for health care items or services provided to Medicare beneficiaries during the period of deactivation because the regulations expressly prohibit CMS from doing so.   42 C.F.R. §§ 424.540(e), 424.555(b); 86 Fed. Reg. 62,240, 62,359-60 (Nov. 9, 2021); see also Goffney v. Becerra, 995 F.3d 737, 743 (9th Cir. 2021).  I only have authority to determine if CMS properly set the date of reactivation.  See 42 C.F.R. § 498.3(b)(15).  In this case, CMS did so. 

VIII.  Conclusion

The effective date for the reactivation of Petitioner’s Medicare billing privileges and the reassignment of Medicare benefits is November 26, 2025.