Donna DiStefano, DAB CR6966 (2026)

DECISION

Petitioner, Donna DiStefano, is a clinical social worker, practicing in New Jersey, who participates in the Medicare program as a supplier of services.  After the Medicare contractor deactivated her Medicare billing privileges, Petitioner submitted a new application, seeking to reactivate her enrollment.

Acting on behalf of the Centers for Medicare & Medicaid Services (CMS), the Medicare contractor approved the application, with a reactivation effective date of February 12, 2026.  As a result, Petitioner’s billing privileges lapsed from January 11, 2025, through February 11, 2026.  Petitioner asks that her billing privileges be reinstated retroactively to November 1, 2025, and that the billing gap be removed.

Because Petitioner filed her subsequently-approved reactivation application on February 12, 2026, February 12 is the earliest possible effective date for her Medicare reactivation.  See 42 C.F.R. § 424.540(d)(2).  I have no authority to review the deactivation nor to order retrospective reimbursement for services provided during the period of deactivation.

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Background

The Medicare contractor, Novitas Solutions, Inc., approved Petitioner’s reactivation enrollment application, effective February 12, 2026.  CMS Ex. 2.  In response, Petitioner requested reconsideration.  CMS Ex. 6.  In a reconsidered determination, dated March 18, 2026, a Provider Enrollment Hearing Specialist affirmed the February 12, 2026 effective date.  CMS Ex. 3.

Petitioner appealed, and the matter is now before me.

CMS moves for summary judgment.  However, because neither party proposes any witnesses, an in-person hearing would serve no purpose.  See Acknowledgment and Pre-Hearing Order at 4, 5, 6 (¶¶ 4(c)(iv), 8, 10) (June 2, 2026).  I may therefore decide this case based on the written record, without considering whether the standards for summary judgment are satisfied.  See CRDP ¶ 19b.1

Exhibits.  CMS submits its motion and brief (CMS Br.) with six exhibits (CMS Exs. 1-6).  In the absence of any objections, I admit into evidence CMS Exs. 1-6.

Although directed to do so, Petitioner did not file a brief or any other documents in response to CMS’s submissions.  Pre-Hearing Order at 3-4 (¶ 4).  In deciding this appeal, I consider the arguments made in Petitioner’s Request for Reconsideration (CMS Ex. 6), her hearing request, and documents attached to her hearing request.  See Anil Hanuman, D.O., DAB No. 3080 at 12 (2022).

Discussion

1. On February 12, 2026, Petitioner filed her subsequently-approved Medicare reactivation application, and the effective date of her reactivation can be no earlier than that date.  42 C.F.R. § 424.540(d)(2).2

Enrollment.  Petitioner participates in the Medicare program as a “supplier” of services.  See Social Security Act § 1861(d); 42 C.F.R. §§ 400.202, 498.2.  To receive Medicare payments for the services furnished to program beneficiaries, a supplier must enroll in the

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program.  Act §§ 1835(a), 1842(h)(1); 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.  CMS’s electronic process is referred to as PECOS (Provider Enrollment, Chain, and Ownership System).

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 practitioner submitting a new enrollment application, 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).

Deactivation and reactivation.  The regulations governing reactivation differ in significant ways from the enrollment regulations.  See 86 Fed. Reg. 62,240, 62,359-60 (Nov. 9, 2021).

“Deactivate” means that a supplier’s billing privileges are stopped but can be restored when she submits updated information.  42 C.F.R. § 424.502 (defining “deactivate”).  When a supplier’s billing privileges are deactivated, no payment is made for otherwise Medicare-covered services furnished to beneficiaries.  42 C.F.R. § 424.555(b). If the supplier furnishes those services while deactivated, the expenses incurred are the supplier’s responsibility.  42 C.F.R. § 424.555(c).  CMS may deactivate a supplier’s billing privileges if, among other reasons, the supplier has not submitted any Medicare claims for six consecutive calendar months. 42 C.F.R. § 424.540(a)(1).

To reactivate its billing privileges, the supplier must recertify that its enrollment information currently on file with Medicare is correct, furnish any missing information, as appropriate, and comply with all applicable enrollment requirements.  42 C.F.R. § 424.540(b)(1).  CMS may also require that a deactivated supplier submit a complete enrollment application.  42 C.F.R. § 424.540(b)(2).  The effective date of reactivation of billing privileges is the date on which the Medicare contractor received the supplier’s submissions that were processed to approval.  42 C.F.R. § 424.540(d)(2).

Petitioner’s deactivation and reactivation.  Here, in a letter dated January 10, 2025, the contractor advised Petitioner that, pursuant to 42 C.F.R. § 424.540(a)(1), her Medicare billing privileges were deactivated, effective January 11, 2025, because she had not

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submitted any Medicare claims in more than six consecutive calendar months prior to the date of the letter.  CMS Ex. 1.

On February 12, 2026, Petitioner submitted, via PECOS, a new enrollment application, which, after receiving additional information, the contractor processed to approval.  CMS Ex. 4; see CMS Ex. 5.  February 12 is therefore the effective date for reactivating Petitioner’s billing privileges.  See 42 C.F.R. § 424.540(d)(2).

Petitioner maintains that she was unaware of the deactivation until February 11, 2026, when she learned that submitted claims “were not currently valid.”  She asks that the reactivation date be adjusted to “on or after November 1, 2025,” so that she can be reimbursed for services she has provided.  Hearing Request (E-File #1).

I have no authority to review a deactivation.  Jeffrey K. McIlroy, MD, Inc., DAB No. 3143 at 3-4 (2024); Tosan Fregene, M.D. & Oncology Clinics, Inc., DAB No. 3018 at 3 (2020); see 42 C.F.R. § 498.3(b) (defining “initial determinations” that are subject to review by an ALJ and the Departmental Appeals Board).  Nor may I grant Petitioner an earlier effective date based on any equitable or policy arguments.  Howard M. Sokoloff, DPM, MS, Inc., DAB No. 2972 at 6, 9 (2019); Wishon Radiological Med. Grp., Inc., DAB No. 2941 at 6-7 (2019); Ark. Health Grp., DAB No. 2929 at 7-9 (2019); James Shepard, M.D., DAB No. 2793 at 8 (2017).

Finally, I may not direct the contractor to allow retrospective reimbursement.  A supplier may not receive payment for services or items furnished while deactivated.  42 C.F.R. §§ 424.540(e), 424.555(b).  This represents a departure; CMS previously permitted retrospective billing after reactivation.  In promulgating the new regulation, the Secretary explained the change:

After careful reflection . . . the most sensible approach from a program integrity perspective is to prohibit such payments altogether.  In our view, a provider or supplier should not be effectively rewarded for its non-adherence to enrollment requirements (for example, failing to respond to a revalidation request or failing to timely report enrollment information changes) by receiving payment for services or items furnished while out of compliance.

86 Fed. Reg. 62,240, 62420-21 (Nov. 9, 2021); see Michael B. Zafrani, M.D., DAB No. 3075 at 2 n.1 (2022).

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Conclusion

Because Petitioner filed her subsequently-approved reactivation application on February 12, 2026, February 12, 2026 is the earliest possible effective date for the reactivation.  See 42 C.F.R. § 424.540(d)(2).

I may not review the contractor’s deactivation, and retrospective reimbursement is not available for those whose enrollment has been deactivated.  42 C.F.R. § 424.540(e).