Community Foot & Ankle Center LLC, DAB, CR6935, (2026)

DECISION

This decision affirms the determination of Novitas Solutions (Novitas), a Medicare Administrative Contractor for the Centers for Medicare & Medicaid Services (CMS), that July 17, 2024 is the reactivation effective date of Medicare enrollment and billing privileges for Community Foot & Ankle Center, LLC (hereinafter referred to as “Petitioner”). 

I.  Background and Procedural History

On November 13, 2024, Petitioner requested a hearing before an administrative law judge (ALJ) to contest a reactivation effective date determination. 

The case was assigned to former ALJ Jacinta Alves for hearing and decision.  On November 14, 2024, the Civil Remedies Division acknowledged receipt of the hearing request and issued Judge Alves’ Standing Order,1 as well as the Civil Remedies Division Procedures (CRDP). 

Page 2

On December 17, 2024, CMS filed a pre-hearing brief and motion for summary judgment (CMS Br.) along with 16 exhibits (CMS Exs.). 

On January 16, 2025, Petitioner filed a pre-hearing brief and motion for summary judgment along with several exhibits. 

CMS filed a reply and opposition to Petitioner’s motion for summary judgment on January 28, 2025. 

On February 19, 2025, Petitioner filed a reply and opposition to CMS’s cross motion for summary judgment. 

On December 23, 2025, this case was transferred to my docket. 

II.  Admission of Exhibits and Decision on the Written Record

Absent objection, CMS Exs. 1-16 are admitted into evidence. 

Petitioner filed several exhibits along with its brief (P. Exs.), but the exhibits are not labeled in accordance with the Standing Order.  Standing Order ¶ 5.  However, absent objection, the exhibits will be admitted, as filed, and will be referred to as P. Exs A-G. 

Neither party proposed witnesses in this matter and all filing deadlines have passed.  Therefore, the record is closed.  Because there is no need to conduct a hearing in this case, I will issue a decision based on the written record.  Standing Order at 14; CRDP ¶ 19d.  I deny CMS’s motion for summary judgment and Petitioner’s cross-motion for summary judgment as moot. 

III.  Issues

Whether Novitas, acting on behalf of CMS, properly established July 17, 2024, as the reactivation effective date for Petitioner’s enrollment in the Medicare program. 

IV.  Jurisdiction

I have jurisdiction to hear and decide this case.  42 C.F.R. § 498.3(b)(15). 

V.  Legal Authorities

The Social Security Act (Act) establishes the enrollment process for providers and suppliers participating in Medicare or Medicare related programs.  42 U.S.C. §§ 1302, 1395cc(j).  Under the Act, “suppliers” are physicians or other practitioners, a facility or

Page 3

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). Providers include hospitals, skilled nursing facilities, and home health agencies.  42 U.S.C. § 1395x(u).  Petitioner is a “supplier.”  42 U.S.C. § 1395x(d); 42 C.F.R. § 400.202. 

A provider or supplier must be enrolled in the Medicare program in order to receive payment for covered items or services from either Medicare (in the case of an assigned claim) or a Medicare beneficiary.  42 C.F.R. § 424.505.  If enrolled, the provider or supplier receives billing privileges and is issued a valid billing number effective for the date a claim was submitted for an item that was furnished or a service that was rendered. 42 C.F.R. § 424.505. 

Once enrolled, CMS may deactivate a provider or supplier’s Medicare billing privileges for any of the reasons listed at 42 C.F.R. § 424.540(a).  If CMS deactivates a supplier’s Medicare billing privileges, then the supplier may file a rebuttal to the deactivation.  42 C.F.R. §§ 424.545(b), 424.546(a)(1).  When CMS issues a determination based on a rebuttal, that determination is not an appealable initial determination.  42 C.F.R. § 424.546(f). 

The determination of a supplier’s effective date is an initial determination subject to ALJ review.  42 C.F.R. § 498.3(b)(15).  However, unlike the determination of a supplier’s effective date, “[e]nrollment applications that are rejected are not afforded appeal rights.” 42 C.F.R. § 424.525(d); see 42 C.F.R. § 498.3(b). 

VI.  Findings of Fact

Petitioner is a clinic/group practice enrolled as a supplier in the Medicare program since 2015.  P. Br. at 2; CMS Ex. 1. 

On February 29, 2024, Novitas Solutions (Novitas), a CMS contractor, issued a notice requesting that Petitioner revalidate its Medicare enrollment record by May 31, 2024. CMS Ex. 2. 

On April 30, 2024, Petitioner submitted a CMS-855R application indicating that the reason for submission was for a supplier or provider “terminating a current reassignment of benefits from a practitioner”.  CMS Ex. 3 at 1. 

On June 3, 2024, Novitas issued a notice informing Petitioner that, effective the date of the notice, all Medicare payments were placed on hold due to Petitioner’s failure to revalidate its enrollment record.  CMS Ex. 4. 

Page 4

Novitas issued a notice on July 5, 2024, informing Petitioner that its Medicare billing privileges were suspended effective June 1, 2024, due to failure to timely revalidate its enrollment record.  CMS Ex. 5. 

The MAC received Petitioner’s initial CMS-855B Medicare revalidation application on July 17, 2024, via mail.  CMS Ex. 6 at 141. 

Petitioner submitted a letter dated July 24, 2024, requesting assistance from a Medicare Provider Enrollment Specialist.  Specifically, Petitioner requested help with revalidation and “inadvertent changes that occurred for my business/office.”  P. Ex. D.  The letter also stated, “we tried to complete everything online in April 2024, but I guess it didn’t go through.”  Id. 

Novitas acknowledged receipt of Petitioner’s Medicare enrollment application on July 29, 2024.  CMS Ex. 7.  Novitas also requested a copy of recent DEA information, that Petitioner submit Sections 2 and 3 of the application, and sign Section 15.  CMS Ex. 8 at 2.  Novitas issued another development request on August 20, 2024.  CMS Ex. 9. 

Petitioner responded to the development requests on August 21, 2024 and September 4, 2024.  CMS Exs. 10, 11. 

Novitas issued an additional development request on September 5, 2024.  CMS Ex. 12 at 1. 

On September 21, 2024, Novitas informed Petitioner that its reactivation enrollment application was approved, but there would be a gap in billing privileges from June 1, 2024 through July 16, 2024, due to failure to fully revalidate during a previous revalidation cycle, and that Petitioner would not be reimbursed for services provided to Medicare beneficiaries during those dates.  CMS Ex. 13.  

Petitioner submitted a reconsideration request on October 2, 2024, requesting that the gap in billing privileges be reinstated due to financial hardship.  CMS Ex. 14 at 3. 

Novitas, on behalf of CMS, issued an unfavorable reconsideration request decision on October 4, 2024.  CMS Ex. 16.  However, the hearing officer adjusted the deactivation date to June 3, 2024, the date of the stay of enrollment.  CMS Ex. 16 at 4.  The gap in billing privileges was changed to June 3, 2024 through July 16, 2024.  Id. 

VII.  Analysis

CMS may deactivate Medicare billing privileges if a provider or supplier does not furnish complete and accurate information and all supporting documentation within 90 calendar days of receipt of notification from CMS to submit an enrollment application and

Page 5

supporting documentation, or resubmit and certify to the accuracy of its enrollment information.  42 C.F.R. § 424.540(a)(3).  Once Medicare billing privileges are deactivated, the effective date of the reactivation of billing privileges is the date on which the Medicare contractor received the provider’s or supplier’s reactivation submission that was processed to approval by the Medicare contractor.  42 C.F.R. § 424.540(d)(2). 

Petitioner claims that on April 30, 2024, the online Medicare Provider Enrollment, Chain, and Ownership System (PECOS) confirmed that “all documents and signatures have been received for your Medicare enrollment application.” P. Br. at 4.  However, Petitioner fails to acknowledge that it submitted the wrong application on April 30^th.  As previously stated, Petitioner submitted CMS-855R application indicating that the reason for submission was “terminating a current reassignment of benefits from a practitioner”.  CMS Ex. 3 at 1.  This is different from the CMS-855B Medicare revalidation application that Petitioner submitted on July 17, 2024 to revalidate enrollment. 

Petitioner also argues that PECOS was inoperable and multiple calls to support staff did not remedy the issues until April 30, 2024.  P. Br. at 4.  According to Petitioner, the support staff members were “misled by their own system” and required the assistance of a supervisor to resolve the issues.  Id.  However, the Board has ruled that difficulty with navigating PECOS does not present a legal ground for the Board or an ALJ to set an earlier effective date.  Chaplin Liu, M.D., DAB. No. 2976 at 9-10 (2019). 

Petitioner argues that they made many attempts to resolve the issue through repeated calls to Novitas and that they made every attempt to comply with the revalidation request.  The excuses provided by Petitioner do not provide a legal basis for me to determine that the reactivation effective date is incorrect.  To the extent that Petitioner is requesting equitable relief, I have no authority to reverse CMS’s determination on equitable grounds.  Iowa Cancer Specialists, PC, DAB No. 3109 at 8 (citing Edward J.S. Picardi, M.D., DAB No. 3045 at 17 (2021); Anil Hanuman, D.O., DAB No. 3080 at 10 (2022)). 

In this case, Petitioner’s Medicare billing privileges were deactivated effective June 3, 2024, for failure to revalidate enrollment within the specified time period.  CMS Ex. 16 at 5.  It is undisputed that Petitioner filed an enrollment application that Novitas was able to subsequently process to approval on July 17, 2024.  CMS Ex. 7.  Based on the evidence provided, I find that the hearing officer did not err in determining that Petitioner’s reactivation effective billing date is July 17, 2024. 

Page 6

VIII.  Conclusion

For the reasons stated above, I find that Novitas, on behalf of CMS, correctly determined that Petitioner’s reactivation effective date for Medicare enrollment and billing privileges is July 17, 2024.  Therefore, CMS’s determination is AFFIRMED.