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                              Kaci D. Sims, MD, DAB CR5791 (2020)
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Kaci D. Sims, MD, DAB CR5791 (2020)








  
  
    

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





Kaci D. Sims, MD
(NPI No.: 1275976557; PTAN: A00366D),
Petitioner,

v.

Centers for Medicare & Medicaid Services.
Docket No. C-20-754Decision No. CR5791December 31, 2020

        
              
    

      DECISION

I sustain the determination of a Medicare contractor, as affirmed on reconsideration, to assign an effective Medicare participation date of January 8, 2020 (with retroactive billing privileges beginning December 9, 2019) to Petitioner, Kaci D. Sims, MD.

I. Background

The Centers for Medicare & Medicaid Services (CMS) filed a brief and eight supporting exhibits, identified as CMS Ex. 1-CMS Ex. 8.  Petitioner filed a statement in support of her hearing request.  With that statement Petitioner filed two exhibits, consisting of a copy of an e-mail from CMS to Petitioner dated September 18, 2019, and a second document from CMS entitled "Electronic Signature Status."  Petitioner did not identify these documents as exhibits.  I identify the e-mail as P. Ex. 1 and the "Electronic Signature Status" document as P. Ex. 2.

**Page 2**

CMS objected to my receiving these exhibits into evidence on the ground that the documents were new evidence, that Petitioner failed to submit them in connection with its request for reconsideration, and also on relevance grounds.  While I agree with CMS that these exhibits technically are excludable, I receive these exhibits into evidence.  The exhibits are documents generated by CMS that clarify the history of Petitioner's applications for reassignment of Medicare billing privileges.  CMS is not prejudiced by my receiving them.  I receive CMS Ex. 1-CMS Ex. 8 and P. Ex. 1-P. Ex. 2 into the record.

CMS's exhibits include a declaration by Randi Heyward, a provider enrollment manager for a Medicare contractor.  CMS Ex. 8.  Petitioner did not request to cross-examine this witness.  *See* Standing Order ¶¶ 10, 11.  For that reason, this case is ripe for a decision based on the parties' written exchanges.

II. Issue, Findings of Fact and Conclusions of Law

**A. Issue**

The issue is whether a Medicare contractor properly assigned an effective date of January 8, 2020, to Petitioner for reassignment of her Medicare billing privileges.

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

Petitioner, a physician, filed an application with a Medicare contractor on July 11, 2019, to reassign her Medicare billing privileges to a third-party supplier of Medicare services.  CMS Ex. 1.  The contractor concluded that this application was incomplete and sent a development request (a request for additional information) to the person who was listed on the July 11 application as Petitioner's contact person.  *Id.* at 2.  The contractor did not receive a response to this request within 30 days.  On August 21, 2019, the contractor rejected Petitioner's application.  CMS Ex. 3.

The contractor advised Petitioner that she would have to submit a new application for reassignment of billing privileges.  CMS Ex. 3 at 1.  On September 18, 2019, Petitioner submitted her electronic signature to the contractor but did not file a new application on that date.  P. Ex. 2.

On January 8, 2020, Petitioner submitted a new application for reassignment of her Medicare billing privileges.  CMS Ex. 4.  The contractor accepted this application and awarded an effective reassignment date to Petitioner of January 8, 2020, with the authority to bill retroactively for services performed beginning December 9, 2019.

**Page 3**

Petitioner challenges the contractor's determination, seeking an earlier effective reassignment of billing privileges date.

There are specific regulatory criteria that apply here.  The rejection of a supplier's Medicare enrollment application is not appealable.  42 C.F.R. § 424.525(d).  I am foreclosed from considering the merits of the contractor's rejection of Petitioner's July 11, 2019 application.  The only recourse available to a supplier whose application is rejected is to submit a new application.

As a general rule, the *earliest* effective date that a supplier may participate in Medicare is the date when a contractor receives an enrollment application that it successfully processes.  42 C.F.R. § 424.520(d).  If a supplier whose application is denied reapplies, the earliest effective date that the supplier may participate in Medicare is the date of the new application, assuming that the contractor accepts it.  Nothing in the regulations permits the applicant to obtain billing privileges at an earlier date.

Petitioner had no recourse but to reapply for reassignment of billing privileges once the contractor rejected her July 11, 2019 application.  She filed her second application on January 8, 2020.  The contractor's acceptance of that application means that January 8, 2020 (with the authority to bill retroactively for services provided beginning December 9, 2019) is the *earliest* effective date for reassignment of Petitioner's billing privileges.  By law, she may not receive an earlier effective date for reassignment.

Petitioner appears to argue that she submitted an application for reassignment on September 18, 2019, and that the contractor should have established that date as the effective date of her reassignment of billing privileges.  Petitioner has not proven that she filed an application on September 18.

Petitioner relies on P. Ex. 1 as support for her contention.  The exhibit is a form e-mail that recites that:  "[t]his message is to confirm receipt of your Medicare enrollment application . . . ."  P. Ex. 1.  Although the language of the form e-mail seems to confirm that Petitioner submitted a new application on September 18, other facts establish that this wasn't the case.

First, September 18, 2019, is the date that Petitioner filed her electronic signature with the contractor.  That was not a new application but rather, a belated submission of information pertinent to Petitioner's rejected July 11, 2019 application.  The e-mail, when read in context, clearly appears to have responded to the submission of the electronic signature and not to the submission of a new application on September 18, 2019.  Further confirmation for this conclusion lies in the fact that the tracking ID number on the e-mail is the same tracking number

**Page 4**

that the contractor used for Petitioner's July 11, 2019 application.  *See* CMS Ex. 1 at 1; P. Ex. 1.  In other words, the e-mail confirms only that Petitioner submitted information relating to the rejected July 11, 2019 application.

Thus, the facts establish that Petitioner filed two applications for reassignment of her billing privileges – an application of July 11, 2019, that was rejected by the contractor, and an application of January 8, 2020, that the contractor accepted.  There is no persuasive proof that Petitioner filed an application on September 18, 2019.
  
          /s/
        Steven T. Kessel

                      Administrative Law Judge Back to top
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