Health Law Daily Wrap Up, CONDITIONS OF PARTICIPATION—DAB DECISIONS: Second application sets Medicare billing clock, (Sep 10, 2026)

By WK Editorial Staff

A rejected enrollment filing could not support an earlier effective date when the supplier later submitted a complete application that CMS approved.

An HHS administrative law judge upheld a Medicare contractor’s determination that a non-physician supplier’s billing privileges took effect on January 20, 2026, the filing date of her subsequently approved enrollment application. The judge also found that December 21, 2025, was the earliest available retrospective billing date because the governing regulation permits qualifying non-physician suppliers to bill retrospectively for no more than 30 days before the effective date. The supplier could not obtain an earlier date based on services furnished before that period (Connie Situ, DAB No. CR6948, Doc. No. C-26-627 (July 27, 2026)).

Medicare requires a prospective supplier to enroll before receiving payment for covered services furnished to beneficiaries. Enrollment allows CMS and its contractors to identify the supplier, validate eligibility, confirm ownership and practice-location information, and grant billing privileges. For a non-physician supplier, 42 C.F.R. § 424.520(d) establishes the effective date as the later of the date the supplier files an enrollment application that CMS later approves or the date the supplier first begins furnishing services at a new practice location.

The supplier first submitted an application in November 2025 to reassign Medicare benefits to a group practice. The contractor requested an accurate Medicare identification number for the entity receiving the reassignment and warned that it could reject the filing if the supplier did not provide complete information within 30 calendar days. After the supplier did not respond, the contractor rejected the application under 42 C.F.R. § 424.525. The regulation does not provide appeal rights for rejected enrollment applications.

The supplier submitted a new initial enrollment application and a new reassignment application on January 20, 2026. The contractor approved those filings. Because the January applications were the applications that CMS ultimately approved, the judge applied § 424.520(d) and treated January 20 as the effective date of the supplier’s Medicare billing privileges.

The supplier sought an October 21, 2025, reassignment date to align Medicare billing with the date she began furnishing services through the group practice. The judge rejected that request because 42 C.F.R. § 424.521(a) allows a non-physician supplier or organization to bill retrospectively for up to 30 days before the effective date when CMS determines that the regulatory conditions are met. Using the January 20 effective date, the decision identified December 21, 2025, as the earliest possible retrospective billing date.

The judge also concluded that equitable considerations could not support additional relief. Although CMS may have discretion to grant additional retrospective billing in circumstances allowed by the regulations, an administrative law judge must apply the governing enrollment rules and may not extend the billing period based on fairness arguments. The judge therefore affirmed the contractor’s reconsidered determination.

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