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                              High Country Community Health, DAB CR6184 (2022)
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High Country Community Health, DAB CR6184 (2022)








  
  
    

  
      
Department of Health and Human Services 
    DEPARTMENTAL APPEALS BOARD
          Civil Remedies Division





High Country Community Health
(PTAN: 861892 / NPI: 1518620665),
Petitioner,

v.

Centers for Medicare and Medicaid Services,
Respondent.
Docket No. C-22-696Decision No. 6184November 2, 2022

        
              
    

      DECISION

I grant summary judgment in favor of the Centers for Medicare & Medicaid Services (CMS), sustaining its determination to enroll Petitioner, High Country Community Health in the Medicare program with an effective date of participation of March 18, 2022.

I.   Background

Petitioner filed a hearing request to challenge a Medicare contractor’s enrollment determination as affirmed on reconsideration.  CMS moved for summary judgment.  Petitioner cross-moved for summary judgment.

There are no disputed issues of material fact in this case and, therefore, summary judgment is appropriate.  CMS filed 22 exhibits in support of its motion, identified as CMS Ex. 1- CMS Ex. 22.  Petitioner filed nine exhibits, identified as P. Ex. 1- P. Ex. 9.

Page 2

It is unnecessary that I admit these exhibits as there are no disputed fact issues.  I cite to some of the exhibits in this decision but only to illustrate facts that are not in dispute.1

II.   Issue, Findings of Fact and Conclusions of Law

**A.   Issue**

The issue is whether a Medicare contractor, acting on behalf of CMS, assigned an effective Medicare participation date to Petitioner that is consistent with regulatory requirements.

**B.   Findings of Fact and Conclusions of Law**

Petitioner sought to participate in Medicare as a Federal Qualified Health Center (FQHC).  In order to be accepted for enrollment, Petitioner had to prove that it met applicable legal requirements, including those established by regulation at 42 C.F.R. Part 491 and 42 C.F.R. Subpart X.

Petitioner filed an enrollment application with a Medicare contractor on October 26, 2021.  CMS Ex. 13 at 2-4.  The contractor found a discrepancy in the application.  The address supplied by Petitioner did not match the business address that the contractor had on file.  This discrepancy was not resolved to the contractor’s satisfaction.2  On December 14, 2021, the contractor rejected Petitioner’s application, because of the address discrepancy.  CMS Ex. 22 at 8.

Petitioner filed a second application for participation on December 17, 2021.  The contractor rejected this application on February 3, 2022, again citing the address discrepancy, among other reasons, as a ground for rejection.  CMS Ex. 14 at 1.

Petitioner filed its third application on February 7, 2022.  CMS Ex. 15 at 1-2.  Petitioner then requested that this application be withdrawn, and the contractor closed the application for that reason.  CMS Ex. 17 at 1.

On February 18, 2022, Petitioner filed a fourth application for participation.  CMS Ex. 16 at 1.  On March 10, 2022, Petitioner submitted a signed and dated statement to the

Page 3

contractor that cited its current practice location address.  CMS Ex. 12.  On March 18, 2022, the contractor accepted this application as meeting all federal participation requirements and granted Petitioner an effective enrollment date as of March 18, 2022.  CMS Ex. 6 at 1; *see* CMS Ex. 18 at 3.

Petitioner, dissatisfied with the effective enrollment date determined by the contractor, filed a request for reconsideration, asserting that its effective enrollment date should be January 3, 2022.  CMS Ex. 2; CMS Ex. 3.  The contractor reconsidered its determination and affirmed it.  CMS Ex. 1.

The contractor rejected or closed Petitioner’s first three applications.  These actions are not appealable.  42 C.F.R. § 424.525(d).  The only issue that I have authority to hear and decide is whether the effective participation date that the contractor assigned to Petitioner is consistent with applicable regulatory requirements that govern the contractor’s processing of Petitioner’s February 18, 2022 application.

Regulations govern the effective date of participation in Medicare of a FQHC such as Petitioner.  That date will be:

[T]he date on which CMS accepts a signed agreement which assures that the . . . FQHC meets all Federal requirements.

42 C.F.R. § 489.13(a)(2)(i).  In this case the undisputed facts are that on March 18, 2022, the contractor accepted Petitioner’s February 18, 2022 application for participation.  By regulation, that date – and only that date – may be Petitioner’s effective participation date.  I sustain the contractor’s effective date determination for that reason.

In its cross-motion for summary judgment Petitioner contends that the contractor erroneously denied Petitioner’s first application.  It asserts that the address that it listed on that application, and all other information that it provided to the contractor, was in fact, correct.

I do not address this claim because I am without authority to decide whether the contractor’s rejection of Petitioner’s first application (or its rejection of the second application) was incorrect.  As I have explained, a contractor’s rejection of an application is not appealable.  42 C.F.R. § 424.525(d).

Petitioner also asserts that other divisions of CMS recognize Petitioner’s address as being the same address as that which Petitioner used in its first application.  It argues that as a matter of reason the contractor should have accepted this address and found Petitioner’s first application to be acceptable.  I do not have authority to decide whether the contractor should have accepted an address for Petitioner other than that which it ultimately accepted.

Page 4

Not only do I lack authority to hear a challenge to a rejection of an application, but I also lack authority to look behind a contractor’s determination to decide whether the contractor ought to have accepted information other than what it found to be acceptable.  My authority is extremely limited here – I may only decide whether the effective date of participation accorded to Petitioner is the same date as the date that the contractor ultimately found Petitioner’s application to be acceptable.

Endnotes

1 CMS objected to Petitioner’s proposed exhibits, P. Ex. 3- P. Ex. 9, and to its proposal to call two witnesses.  I do not rule on these objections because I grant summary judgment in favor of CMS.

2 In an attempt to resolve the discrepancy, the contractor sent a letter to Petitioner on November 2, 2021, advising Petitioner of the discrepancy and giving Petitioner 30 days within which to resolve that issue.  CMS Ex. 22 at 4-5.
  
          /s/
        Steven T. Kessel

                      Administrative Law Judge Back to top
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