Connie Situ, DAB CR6948 (2026)

DECISION

Petitioner, Connie Situ, is a physician assistant, practicing in New Jersey, who participates in the Medicare program as a supplier of services.  On January 20, 2026, she applied to participate in the Medicare program as a supplier of services and to reassign her Medicare benefits to Physiatry Consultants of NJ, LLC, a group practice.  The Medicare contractor, acting on behalf of the Centers for Medicare & Medicaid Services (CMS), has granted her application, with a “retrospective billing date” of December 21, 2025.  Petitioner now asks for an earlier date.

Because she filed her subsequently-approved application on January 20, 2026, and a reassignment of benefits can be effective up to 30 days before the application to reassign benefits is submitted, January 20, 2026 is the earliest effective billing date, and December 21, 2025 is the earliest possible retrospective billing date.

Background

In a notice letter, dated February 3, 2026, the Medicare contractor, Novitas Solutions, advised Petitioner Situ that it approved her “initial enrollment and reassignment application(s)” with a “reassignment effective date” of December 21, 2025.  CMS Ex. 5.  Petitioner requested reconsideration, asking that the date of reassignment be changed to

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October 21, 2025, in order to “align[] with the actual start of services provided under our group.”  CMS Ex. 6.

In a reconsidered determination, dated April 27, 2026, the Medicare contractor affirmed the initial determination, concluding that Petitioner’s “effective date of Medicare billing” is January 20, 2026, and that December 21, 2025, is the earliest possible retrospective billing date.  CMS Ex. 7 at 3.

Petitioner appealed, and the matter is now before me.

Decision on the written record.  CMS has moved for summary judgment.  However, because neither party proposes any witnesses, an in-person hearing would serve no purpose.  See Acknowledgment and Prehearing Order at 4, 5, 6 (¶¶ 4(c)(iv), 8, 10) (May 11, 2026).  I may therefore decide this case based on the written record, without considering whether the standards for summary judgment are satisfied.  See Anil Hanuman, D.O., DAB No. 3080 at 12 (2022).

That I decide this case based on the written record does not mean that Petitioner has not had a hearing.  Courts recognize that, although a case may be decided on summary judgment or based on the written record, the administrative law judge, by considering the evidence and applying the law, has granted the petitioner a hearing.  See CNG Transmission Corp. v. FERC, 40 F.3d 1289, 1293 (D.C. Cir. 1994) (holding that a “paper hearing” satisfies statutory requirements for “notice and opportunity for hearing.”).

The parties’ submissions.  CMS submits its motion and brief (CMS Br.) with six exhibits (CMS Exs. 1-2 and 4-7).   Although CMS lists CMS Ex. 3 (January 14, 2026 rejection letter) on its exhibit list, it neglected to submit the document.

Disregarding my prehearing order, Petitioner did not file a brief or any other documents in response to CMS’s submissions.  Prehearing Order at 3 (¶ 4).  Absent Petitioner’s showing good cause for failing to comply with my order, I could dismiss this appeal.  See El Med., Inc., DAB No. 3117 at 15 (2023); Chit-Chat, Inc., DAB No. 2036 at 9 (2019) (“Compliance with ALJ orders is not optional.”).  Instead, I decide the appeal, considering the arguments made in Petitioner’s Request for Reconsideration and its Request for an Administrative Law Judge Hearing.  See Hanuman, DAB No. 3080 at 12.

In the absence of any objections, I admit into evidence CMS Exs. 1-2 and 4-7.  See Prehearing Order at 5 (¶ 7).

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Discussion

1. Because she filed her subsequently-approved applications to enroll and to reassign benefits on January 20, 2026, January 20 is her earliest possible effective date for Medicare billing and December 21, 2025, is the earliest possible retrospective billing date.  42 C.F.R. §§ 424.520(d), 424.521(a), 424.522(a).1

Enrollment.  Petitioner Situ applied to participate in the Medicare program as a “supplier” of services.  Social Security Act (Act) § 1861(d); 42 C.F.R. § 498.2.  To receive Medicare payments for the services furnished to program beneficiaries, a prospective supplier must enroll in the program.  Act § 1834(j)(1)(A); 42 C.F.R. § 424.505.  “Enrollment” is the process by which CMS and its contractors:  1) identify the prospective supplier; 2) validate the supplier’s eligibility to provide items or services to Medicare beneficiaries; 3) identify and confirm a supplier’s owners and practice location; and 4) grant the supplier Medicare billing privileges. 42 C.F.R. § 424.502.

To enroll, a prospective supplier must complete and submit an enrollment application.  42 C.F.R. §§ 424.510(d)(1), 424.515(a).  An enrollment application is either a CMS-approved paper application or an electronic process approved by the Office of Management and Budget.  42 C.F.R. § 424.502.2   When CMS determines that a prospective supplier meets the applicable enrollment requirements, it grants Medicare billing privileges, which means that the supplier can submit claims and receive payments from Medicare for covered services provided to program beneficiaries.  For a non-physician, the effective date for billing privileges “is the later of the date of filing” a subsequently-approved enrollment application or “the date that the supplier first began furnishing services at a new practice location.”  42 C.F.R. § 424.520(d) (Emphasis added).

A supplier may reassign her billing privileges under certain circumstances, including where the reassignment is to an employer or to a Medicare-enrolled entity pursuant to a contractual arrangement under which the entity bills for the supplier’s services.  42 C.F.R. § 424.80(b), (d).

Petitioner’s enrollment:  the first application.  On November 26, 2025, Petitioner submitted to the Medicare contractor an application to reassign benefits to Physiatry Consultants of NJ, LLC.  CMS Ex. 1.  However, in a letter dated December 8, 2025, the Medicare contractor directed her to submit additional information:  an accurate Medicare identification number for the supplier to whom her benefits were to be reassigned.

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The letter warned that the supplier might reject her application if she did not furnish the complete information within 30 calendar days from the postmarked/emailed date of the letter.  CMS Ex. 2.  When Petitioner did not respond, the contractor rejected her application pursuant to 42 C.F.R. § 424.525.  CMS Ex. 7 at 2.  Enrollment applications that are rejected are not afforded appeal rights.  42 C.F.R. § 424.525(d).

Petitioner’s enrollment:  the subsequently-approved application.  On January 20, 2026, Petitioner filed another initial application (CMS 855I) and another application to reassign her Medicare benefits (CMS-855R), which the contractor subsequently approved.  CMS Exs. 4, 5.  Thus, pursuant to section 424.520(d), the date Petitioner filed her subsequently-approved enrollment applications, January 20, 2026, is the correct effective date of enrollment.  Howard M. Sokoloff, DPM, MS, Inc., DAB No. 2972 (2019); Urology Grp. of NJ, LLC, DAB No. 2860 (2018); Willie Goffney, Jr., M.D., DAB No. 2763 at 7 (2017), aff’d, Goffney v. Azar, No. CV 17-8032 MRW (C.D. Cal. Sept. 25, 2019).

A non-physician or non-physician organization may retrospectively bill for services for up to 30 days prior to the effective date, if CMS determines that certain circumstances are met.  42 C.F.R. § 424.521(a).  Thus, December 21, 2025 is Petitioner’s earliest possible retrospective billing date.

Petitioner asks that her retrospective billing date be adjusted retroactively to align with “the actual start of services provided under our group, Physiatry Consultants of NJ LLC.”  CMS Ex. 6.

CMS may have the discretion to grant additional days of retrospective billing, but I do not.  I am bound by the regulations and have no authority to grant Petitioner the relief she requests.  It is well-settled that an administrative law judge may not grant relief based on equitable arguments.  Sokoloff, DAB No. 2972 at 9.

Conclusion

I affirm the contractor’s reconsidered determination.  On January 20, 2026, Petitioner filed her subsequently-approved Medicare applications.  January 20 is therefore the effective date of Medicare billing privileges.  42 C.F.R. § 424.520(d).  CMS also acted within its authority when it granted a retrospective billing date of December 20, 2025.  42 C.F.R. § 424.521(a).