Wantage Township First Aid Squad, ALJ Ruling 2026-4 (HHS CRD January 13, 2026)

DISMISSAL

For the reasons set forth below, I conclude that, because the Centers for Medicare & Medicaid Services (CMS) has not issued an adverse reconsidered determination and because the issues presented in Petitioner’s hearing request are no longer in controversy, Petitioner, Wantage Township First Aid Squad, is not entitled to Administrative Law Judge (ALJ) review in this matter.  I therefore dismiss the Petitioner’s hearing request pursuant to 42 C.F.R. § 498.70(b).

Background

Petitioner is a supplier of ambulance services in Wantage, New Jersey.  It applied to enroll in the Medicare program as a supplier of services.  CMS Ex. 1.  In a letter dated September 5, 2024, the Medicare contractor, Novitas Solutions, Inc., denied enrollment, concluding, based on an August 27, 2024 site visit, that the supplier was not in business.  Request for Hearing Supporting Documents (E-file ## 1a, 1b); CMS Ex. 2; see 42 C.F.R. § 424.530(a)(5) (authorizing denial of enrollment if CMS determines, based on on-site review, that the prospective supplier is not operational to provide covered items or services).

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Petitioner sought reconsideration.  Petitioner asserted that it was in business, and that any assertion to the contrary was incorrect.  According to Petitioner, the information had been provided by an individual who was not employed by the ambulance service.  Petitioner explained that it was not at the site on August 27, when the inspector arrived, because it was out on a 911 call.  Request for Hearing Supporting Documents (E-file # 1c).

In a reconsidered determination, dated January 8, 2025, a CMS hearing officer reversed the initial determination, finding, based on a December 23, 2024 site visit, that the supplier was operational.  The hearing officer directed CMS to instruct the contractor to process Petitioner’s enrollment application.  Request for Hearing Supporting Documents (E-file # 1d); CMS Ex. 3.  Nothing in this record suggests that CMS failed to comply with the hearing officer’s directive.1

CMS now moves to dismiss Petitioner’s appeal, arguing that:  1) the facility is not entitled to a hearing because CMS issued a favorable reconsidered determination; and 2) the issues presented by the hearing request are no longer in controversy.  Petitioner did not respond to CMS’s Motion to Dismiss.  See 42 C.F.R. § 498.17(b) (allowing a party 20 days in which to submit any rebuttal statements or additional evidence).

Discussion

1. Petitioner has no right to a hearing because the Centers for Medicare & Medicaid Services issued a favorable reconsidered determination.2

The hearing rights of a prospective supplier are established by federal regulations at 42 C.F.R. Part 498.  A facility dissatisfied with an initial determination is entitled to further review, but administrative actions that are not initial determinations are not subject to appeal.  42 C.F.R. § 498.3(a), (d).  The regulations specify which actions are “initial determinations” and set forth examples of actions that are not.  The determination to deny a prospective supplier’s Medicare enrollment is listed as an initial determination.  42 C.F.R. § 498.3(b)(17).  A determination that grants enrollment is not.  Because Petitioner’s enrollment has been approved, and the determination from which Petitioner appeals is not an initial determination, Petitioner is not entitled to an ALJ hearing.

The regulations separately specify a prospective supplier’s appeal rights.  A prospective supplier who is dissatisfied with a reconsidered determination related to the “denial . . . of Medicare billing privileges” is entitled to a hearing before an ALJ.  42 C.F.R.

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§ 498.5(l)(1), (2).  Because the reconsidered determination here approved Petitioner’s Medicare billing privileges, Petitioner is not entitled to a hearing under section 498.5.

Finally, the regulations authorize an ALJ to dismiss a hearing for cause if the requesting party does not otherwise have a right to a hearing.  Here, the favorable reconsidered determination is not an appealable initial determination under section 498.3.  Nor is it a reconsidered determination related to the denial of Medicare billing privileges.  Petitioner thus does not have the right to a hearing before an ALJ.

Conclusion

Because Petitioner does not have the right to a hearing before an ALJ, I dismiss its hearing request.  42 C.F.R. § 498.70(b).