Kennebec Medical Consultants LLC, DAB CR6934 (2026)

DECISION

National Government Services (NGS), a Medicare administrative contractor for the Centers for Medicare & Medicaid Services (CMS), approved the enrollment application of Kennebec Medical Consultants LLC (Petitioner) effective December 10, 2025, a date which NGS 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 August 1, 2025, through December 9, 2025.

My jurisdiction in this matter is limited to determining whether NGS assigned the correct date for reactivation under the law.  I do not have jurisdiction to review NGS’s decision to deactivate Petitioner’s billing privileges or to issue equitable relief.  As to the issue before me, I affirm NGS’s determination that Petitioner’s effective date for reactivation of Medicare billing privileges is December 10, 2025, because that is the date NGS received Petitioner’s reactivation application that it processed to approval.

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I.  Procedural History and Decision on the Record

On February 2, 2026, NGS issued an unfavorable reconsidered determination related to the effective date of reactivation of Petitioner’s Medicare billing privileges.  On March 11, 2026, Petitioner timely requested a hearing to dispute the reconsidered determination.  The matter was assigned to ALJ Benjamin Zeitlin and the Civil Remedies Division (CRD) issued ALJ Zeitlin’s Standing Prehearing Order (Prehearing Order).1

In accordance with the Prehearing Order, CMS timely filed a prehearing brief, which included a motion for summary judgment, and thirteen proposed exhibits (CMS Exs. 1-13).  Petitioner did not file a prehearing brief or proposed exhibits.  On June 18, 2026, Petitioner confirmed by email to the Attorney‑Advisor assisting me in this matter that it had no additional evidence or filings to submit.  DAB E-File Entry No. 6.

Absent objection, I admit CMS’s exhibits 1 through 13 into the record.  Prehearing Order ¶ 10; Civ. Remedies Div. P. § 14(e).  Because neither party has proffered any witnesses, a hearing is not necessary.  I decide this case on the written record, meaning the parties’ written submissions and arguments, and without considering whether the standard for summary judgment is met.  Prehearing Order ¶ 13; Civ. Remedies Div. P. § 19(d).  Therefore, I deny CMS’s summary judgment motion as moot.

In rendering this decision on the record, I address the matters raised by Petitioner in its hearing request.2

II.  Issue

Whether NGS, acting on CMS’s behalf, had a legitimate basis to assign December 10, 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).

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IV.  Findings of Fact

1. Petitioner is a medical group practice located in Maine.  Its NPI is 1821386343, and PTAN is 0023797.  CMS Ex. 12 at 1.
2. On April 30, 2025, NGS mailed a revalidation letter to Petitioner’s practice location and PO Box addresses, informing Petitioner that it was required to revalidate its Medicare enrollment record by July 31, 2025.  CMS Exs. 2 and 3.
3. On August 5, 2025, NGS notified Petitioner that it was placing a stay on Petitioner’s Medicare enrollment record effective August 1, 2025, because Petitioner failed to respond to NGS’s revalidation request, which was due on July 31, 2025.  CMS Ex. 4 at 1 (notice addressed to practice location); CMS Ex. 5 at 1 (notice addressed to PO Box).
4. By notice dated September 16, 2025, NGS notified Petitioner that its Medicare billing privileges were deactivated effective August 1, 2025, because it did not timely revalidate its enrollment record.  CMS Ex. 6 at 1 (notice addressed to practice location); see also CMS Ex. 7 (addressed to PO Box).  NGS advised Petitioner of its right to file a rebuttal if Petitioner did not believe the deactivation determination was correct.  CMS Ex. 6 at 1-2.  There is no evidence or argument that Petitioner submitted a rebuttal.
5. On October 16, 2025, Petitioner filed an enrollment application to reactivate its Medicare billing privileges.  CMS Ex. 8.
6. On October 28, 2025, NGS notified Petitioner that it received its enrollment application but that its application required corrections and supporting documentation.  CMS Ex. 9.  The notice stated that “[w]e may reject your application(s) if you do not furnish complete information within 30 calendar days from the original request date pursuant to [42 C.F.R. § 424.525].”  Id. at 2.
7. By notice dated December 3, 2025, NGS notified Petitioner that its October 16, 2025 application was rejected because it did not respond to NGS’s development request.  CMS Ex. 10 at 1.
8. On December 10, 2025, Petitioner filed another enrollment application to reactivate its Medicare billing privileges.  CMS Ex. 11.
9. On December 22, 2025, NGS issued an initial determination approving Petitioner’s reactivation enrollment application, effective December 10, 2025.  CMS Ex. 12 at 1.  The notice identified a gap in billing privileges “from August 01, 2025 through

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December 10, 2025 for failing to fully revalidate during a previous revalidation cycle.”  Id. 

10. On January 2, 2026, Petitioner requested reconsideration.  CMS Ex. 13.  Petitioner explained that it did not receive NGS’s revalidation notice and that, once it became aware of the requirement, it submitted an enrollment application.  Id. at 1–2.  In regard to its October application, Petitioner acknowledged receiving NGS’s development request but asserted that the issue identified – its legal business name – had not been raised in prior revalidation cycles.  Id.  Nevertheless, according to Petitioner, it promptly attempted to correct the deficiency but experienced delays in obtaining access to the portal needed to update its business name.  Id.  Petitioner further contended that it acted in good faith, made timely efforts to comply with revalidation requirements, continued to provide medically necessary services, and would face disproportionate harm from denial of reimbursement despite the absence of any program integrity concerns.  Id.
11. On February 2, 2026, NGS issued an unfavorable reconsidered determination.  DAB E-File Entry No. 1a.  NGS found that a revalidation notice was issued to Petitioner on April 30, 2025, advising of a July 31, 2025 deadline, and issued a stay of enrollment on August 5, 2025, after the deadline to revalidate passed.  Id. at 2–3.  NGS further determined that Petitioner’s October 16, 2025 revalidation application was rejected because Petitioner did not timely respond to its development request.  Id. at 3.  Petitioner submitted another application on December 10, 2025, which NGS processed to approval.  Id.  Based on these facts, NGS concluded that the reactivation effective date was correct and that the resulting gap in billing privileges was proper, but it corrected the gap to run from August 1, 2025, through the day prior to reactivation, December 9, 2025.  Id. at 4.

V.  Conclusions of Law

1. Based on the reactivation enrollment application that NGS approved in this case, the effective date for reactivation of Medicare billing privileges is the date the approved application was received by NGS, i.e., December 10, 2025.  42 C.F.R. § 424.540(d)(2).
2. Petitioner is not eligible for a retrospective billing period to August 1, 2025, because CMS may not make payment to a supplier for items or services furnished to Medicare beneficiaries while the supplier’s Medicare billing privileges are deactivated.  42 C.F.R. §§ 424.540(e), 424.555(b).

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VI.  Analysis

Petitioner does not want a gap in its Medicare billing privileges from August 1, 2025, through December 9, 2025.  This gap was created when NGS deactivated Petitioner’s Medicare billing privileges because Petitioner failed to revalidate its enrollment records.  Petitioner asks that I consider that it never received a revalidation notice from NGS.  DAB E-File Entry No. 1b, Request for Hearing (RFH); see also CMS Ex. 13.  Petitioner explains that it has a strict internal process for scanning and digitally logging all incoming mail and that its records do not show that it received the revalidation letter purportedly sent by NGS.  RFH.  Petitioner further states that it takes its compliance responsibilities seriously and that, had it received the revalidation notice, it would have addressed it immediately.  Id.  Petitioner requests “that Medicare reconsider the determination and allow [Petitioner’s] enrollment status to be reinstated or the revalidation process to be completed without penalty.”  Id. 

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 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).

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

In this case, NGS issued a notice letter dated September 16, 2025, deactivating Petitioner’s billing privileges because it failed to timely revalidate.  I acknowledge, and have no basis to doubt, Petitioner’s assertion that it did not receive NGS’s revalidation notice.  However, the regulations make 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).  Nor is there any argument or evidence that Petitioner filed a rebuttal, the only review available to it, in response to the deactivation determination.  Therefore, the record shows Petitioner’s billing privileges were deactivated effective August 1, 2025.

On the other hand, the effective date of reactivation is an action over which I do have review authority.  If CMS deactivates a supplier’s billing privileges due to an untimely response to a revalidation request, the supplier may seek reactivation by recertifying the enrollment information on file or, if CMS determines appropriate, by submitting 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 subsequently processed to approval.  42 C.F.R. § 424.540(d)(2).  Notably, the regulation governing reactivation does not permit a retrospective or retroactive billing period.  42 C.F.R. § 424.540(d)(2).

In this case, I find no error in NGS’s determination.  The record shows that NGS received Petitioner’s application on December 10, 2025, and processed it to approval.  CMS Ex. 11.  Accordingly, the effective date of reactivation is December 10, 2025.  I acknowledge that Petitioner submitted an earlier revalidation application on October 16, 2025; however, that application was rejected.  CMS Ex. 10 at 1.  As with deactivation, I do not have authority to review CMS’s rejection of an enrollment application.  42 C.F.R. § 424.525(d) (“Enrollment applications that are rejected are not afforded appeal rights.”).

I recognize that Petitioner does not want a gap in its Medicare billing privileges, and I have no basis to doubt its representations that it did not receive the revalidation notice, that it takes its Medicare compliance responsibilities seriously, or that the gap in billing privileges has caused financial hardship.  However, as explained above, NGS’s decision to deactivate is outside my jurisdiction.  Moreover, 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

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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 December 10, 2025.