Caleb Wright, DAB CR6938 (2026)

This decision affirms the determination of the Centers for Medicare & Medicaid Services (CMS), that February 22, 2025 is the reactivation effective date of Medicare enrollment and billing privileges for Petitioner, Caleb Wright.

I. Background and Procedural History

On June 6, 2025, Petitioner requested a hearing before an administrative law judge (ALJ) to contest a reactivation effective date determination.

On June 9, 2025, the Civil Remedies Division acknowledged receipt of the hearing request and issued my Standing Order, as well as the Civil Remedies Division Procedures (CRDP).  This case was assigned to me for hearing and decision.

On July 9, 2025, Petitioner filed a pre-hearing exchange (P. Br.) along with five exhibits (P. Exs.).1

On July 14, 2025, CMS filed a combined pre-hearing brief (CMS Br.) and motion for summary judgment along with eight exhibits (CMS Exs).

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II. Admission of Exhibits and Decision on the Written Record

Absent objection, CMS Exs. 1-8 and P. Exs. 1-5 are admitted into evidence.

CMS did not offer any witnesses.  Petitioner identified himself as a witness.  P. Br. at 2. However, CMS did not request to cross-examine Petitioner.  Therefore, there is no need to conduct a hearing, and I will issue a decision based on the written record.  Standing Order at 1; CRDP ¶ 19d.

CMS’s motion for summary judgment is denied as moot.

III. Jurisdiction

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

IV. Issue

Whether Noridian, acting on behalf of CMS, properly established February 22, 2025, as the reactivation effective date for Petitioner’s enrollment in the Medicare program.

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 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.

To maintain Medicare billing privileges, suppliers must revalidate their enrollment information at least every five years; however, CMS reserves the right to require revalidation at any time.  When CMS notifies suppliers that it is time to revalidate, the suppliers must submit a signed enrollment application, accurate information, and

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supporting documents within 60 calendar days of CMS’s notification.  42 C.F.R. § 424.515.

Once enrolled, CMS may deactivate a provider or supplier’s Medicare billing privileges for any of the reasons listed at 42 C.F.R. §  24.540(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).

CMS can also 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 a supplier’s 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).  If CMS deactivates a supplier’s billing privileges due to an untimely response to a revalidation request, the enrolled supplier may apply for CMS to reactivate its Medicare billing privileges by completing a new enrollment application or, if deemed appropriate, recertifying its enrollment information that is on file.  42 C.F.R. § 424.540(b)(1).

VI. Findings of Fact

Caleb Wright is a physical therapist and sole owner of Equipped Motion Incorporated, who has been enrolled as a Medicare provider since 2017.  P. Br. at 4.

On June 26, 2024, Noridian Healthcare Solutions (Noridian), a Medicare Administrative Contractor, acting on behalf of CMS, issued a Revalidation Notice informing Petitioner that he was required to revalidate his Medicare enrollment record by September 30, 2024.  CMS Ex. 1.  The notice letter warned that failure to respond may result in the deactivation of Medicare billing privileges and a gap in reimbursement.  Id.  The notice was addressed to Equipped Motion Incorporated at 8828 SE Scottstree Way, Clackamas, OR 97015.  Id.  A second notice was sent on the same date to 14807 SE Oregon Trail Dr., Happy Valley, OR 97015.  CMS Ex. 2.  Petitioner did not respond to the revalidation notice.

On September 23, 2024, Petitioner relocated his practice to a new location at 15630 SE 90^th Avenue, Clackamas, OR 97015, and the mailing address changed to P.O. Box 91, Clackamas, OR 97015.  P. Br. at 7.

On October 2, 2024, Noridian issued a Stay of Enrollment notice informing Petitioner that all Medicare payments were placed on hold due to Petitioner’s failure to revalidate its enrollment record.  CMS Ex. 3.  The notice warned that a failure to respond may result in deactivation of Petitioner’s Medicare enrollment and may cause a gap in

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reimbursement.  Id.  The stay of enrollment notice was sent to the 8828 SE Scottstree Way address.  Id.  Petitioner did not respond to the notice.

On November 7, 2024, Noridian issued a “Stopping Billing Privileges” notice informing Petitioner that its billing privileges were being deactivated effective October 1, 2024, pursuant to 42 C.F.R. 424.540(a)(3), due to failure to timely revalidate its enrollment record.  CMS Ex. 4.  The notice stated that claims would not be paid after the deactivation date.  Id.  The notice was addressed to Equipped Motion Incorporated and sent to the same address as the stay of enrollment notice.  Id.

Petitioner submitted a CMS-855B Medicare enrollment application on February 22, 2025 to revalidate his enrollment.  CMS Ex. 5; P. Br. at 7.

On March 6, 2025, Noridian informed Petitioner that the revalidation application was approved.  CMS Ex. 6.  The letter stated that there would be a gap in billing privileges from October 1, 2024 through February 21, 2025, for 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.  Id.

On March 12, 2025, Petitioner timely requested reconsideration of the reactivation date decision.  P. Br. at 7; CMS Ex. 8.

Noridian issued an unfavorable reconsideration determination on June 4, 2025.  CMS Ex. 8.

VII. Analysis

Petitioner is requesting a review of the gap in billing dates from October 1, 2024 to February 21, 2025, and explains that this was his first experience with recertification since starting Medicare billing in 2017.  P. RFH; P. Br. at 4.  In addition, Petitioner did not receive the notices sent by Noridian because the notices were sent to old addresses, as Petitioner had changed practice locations.  P. Br. at 4.  Petitioner admits to not updating his mailing address in PECOS.  Id.  Petitioner was also undergoing a change in electronic billing software during this time.  P. Br.  As the hearing officer noted, the regulations provide that a provider must report a change of practice location to their Medicare contractor within 30 days.  CMS Ex. 8 at 4; see 42 C.F.R. § 424.516 (d)(1)(iii).

Though I acknowledge Petitioner’s request, I do not have the authority to review the deactivation of Petitioner’s Medicare billing privileges.  Ark. Health Group, DAB No. 2929 at 9 (2019).  If Petitioner was dissatisfied with the deactivation determination, the remedy was to file a rebuttal with Noridian.  CMS Ex. 4.  Neither the deactivation of billing privileges nor the rejection of enrollment applications are “initial determinations”

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subject to ALJ review under 42 C.F.R. Part 498.  See 42 C.F.R. § 424.525(d); 42 C.F.R. § 498.3(b).

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).  In this case, Petitioner’s Medicare billing privileges were deactivated effective October 1, 2024, for failure to revalidate enrollment within the specified time period.  CMS Ex. 4.  It is undisputed that Petitioner filed an enrollment application that Noridian was able to subsequently process to approval on February 22, 2025.  CMS Ex. 6.  Based on the evidence provided, I find that the hearing officer did not err in determining that Petitioner’s reactivation effective billing date is February 22, 2025.

Petitioner argues that he will incur financial hardship if unable to bill for the services provided during the deactivation period.  P. Br. at 6.  While I understand and am sympathetic to Petitioner’s concerns regarding the financial impacts of the billing gap due to the deactivation, the applicable regulation does not provide for a retrospective or retroactive billing period, nor do I have the authority to add a period of retrospective or retroactive billing.  See 42 C.F.R. § 498.3(b)(15).  In addition, the regulations prohibit CMS from paying a supplier for items or services furnished to Medicare beneficiaries during the period of deactivation.  42 C.F.R. §§ 424.540(e), 424.555(b).  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 (2023) 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)).

VIII.  Conclusion

For the reasons stated above, I find that Noridian, on behalf of CMS, correctly determined that Petitioner’s reactivation effective date for Medicare enrollment and billing privileges is February 22, 2025. Therefore, CMS’s determination is AFFIRMED.