Timothy Ekhlassi, M.D., M.P.H., DAB No. 3065 (2022)

FINAL DECISION ON REVIEW OF ADMINISTRATIVE LAW JUDGE DISMISSAL

Timothy Ekhlassi, M.D., M.P.H. (Petitioner) appeals the decision of an Administrative Law Judge (ALJ) upholding the effective date of Petitioner’s Medicare enrollment as determined by a contractor for the Centers for Medicare & Medicaid Services (CMS).  The ALJ upheld the contractor’s reconsidered determination that the effective date of Petitioner’s Medicare enrollment and billing privileges is March 4, 2019, based on the date Petitioner filed the enrollment and reassignment applications that the contractor subsequently approved.  Timothy Ekhlassi, M.D., M.P.H., DAB CR5969 (2021) (ALJ Decision).  We affirm the ALJ Decision because it is supported by substantial evidence and free from legal error.

Legal Background

To receive payment for services furnished to Medicare beneficiaries, “suppliers” must be approved by CMS for “enrollment” in the program.  See 42 C.F.R. §§ 424.500, 424.505, 424.510.1   “Enrollment” is the process that CMS and its contractors use to identify the supplier, validate the supplier’s eligibility to provide items or services to Medicare beneficiaries, identify and confirm a supplier’s practice location and owners, and grant the supplier Medicare billing privileges.  Id. § 424.502 (defining “Enroll/ Enrollment”).  “Supplier” is defined in the applicable regulations to mean “a physician or other practitioner, or an entity other than a provider, that furnishes health care services under Medicare.”  42 C.F.R. § 400.202 (defining supplier).

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A Medicare enrollment application can be either the appropriate version of the paper-form CMS-855 (physicians must complete the CMS-855I (enrollment application)) or via the Provider Enrollment, Chain, and Ownership System (PECOS), an electronic Medicare enrollment process approved by Office of Management and Budget (OMB).2  Id. § 424.502.  An individual physician enrolled in the Medicare program may reassign his or her Medicare payments to an employer.  Id. § 424.80(b)(1).  In order to reassign Medicare benefits, a physician must submit and obtain CMS’s approval of a reassignment application, form CMS-855R (reassignment application).  Gaurav Lakhanpal, MD, DAB No. 2951, at 1-2 (2019) (citing 71 Fed. Reg. 20,754, 20,756 (Apr. 21, 2006)).

CMS may reject a supplier’s enrollment application if the “supplier fails to furnish complete information on the . . . enrollment application within 30 calendar days from the date of the contractor request for the missing information” or the “supplier fails to furnish all required supporting documentation within 30 calendar days of submitting the enrollment application.”  42 C.F.R. § 424.525(a)(1)-(2).  “Enrollment applications that are rejected are not afforded appeal rights.”  Id. § 424.525(d).  In other words, a supplier has no right to administrative review of a contractor’s decision to reject an enrollment application under section 424.525(a).  42 C.F.R. § 424.525(d); James Shepard, M.D., DAB No. 2793, at 3 (2017) (citing Experts Are Us, DAB No. 2322, at 9 n.8 (2010)).  After CMS rejects an enrollment application, the “supplier must complete and submit a new enrollment application and submit all supporting documentation for CMS review and approval.”  Id. § 424.525(c).

If CMS approves an enrollment application, the effective date of billing privileges for a practitioner is the later of:  “(1) The date of filing of a Medicare enrollment application that was subsequently approved by a Medicare contractor; or (2) The date that the supplier first began furnishing services at a new practice location.”  Id. § 424.520(d).  In the preamble to the final rule adopting section 424.520, CMS explained that “date of filing” means “the date that the Medicare . . . contractor receives a signed . . . enrollment application that the Medicare . . . contractor is able to process to approval.”  73 Fed. Reg. 69,726, 69,766-67 (Nov. 19, 2008); Gregory J. Frazer, Au.D., Ph.D., DAB No. 3038, at 2 (2021) (citing Alexander C. Gatzimos, MD, JD, LLC, DAB No. 2730, at 15-17 (2016)).  This also applies to applications submitted through PECOS.  See Gatzimos at 5.

A supplier “may retrospectively bill for services” if the supplier “has met all program requirements . . . and services were provided at the enrolled practice location for up to . . . [t]hirty days prior to the[] effective date if circumstances precluded enrollment in advance of providing services to Medicare beneficiaries.”  42 C.F.R. § 424.521(a)(1); Wishon Radiological Med. Grp., Inc., DAB No. 2941, at 2 (2019).

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The determination of the effective date of a supplier’s billing privileges is an “initial determination” that the supplier may appeal under 42 C.F.R. Part 498.  42 C.F.R. § 498.3(a)(1), (b)(15); Urology Grp. of N.J., DAB No. 2860, at 6 (2018); Victor Alvarez, M.D., DAB No. 2325, at 3 (2010).  A supplier may ask CMS to reconsider the effective date and may request a hearing before an ALJ on the reconsidered determination.  See 42 C.F.R. §§ 498.5(l), 498.5(f); see also Urology Grp. at 6.  Any party dissatisfied with a hearing decision issued by an ALJ may request review of the ALJ decision by the Board.  See 42 C.F.R. § 498.80.

Case Background3

Petitioner is a physician practicing in Bellingham, Washington.  CMS Ex. 3, at 1.  On November 15, 2018, Noridian Health Care Solutions, LLC (Noridian), a Medicare administrative contractor for CMS, received Petitioner’s CMS-855I application to enroll in Medicare and CMS-855R application to reassign Petitioner’s Medicare benefits to Bellingham Bay Ophthalmology LLC.  CMS Ex. 1, at 2.4   In an email dated January 25, 2019, Noridian notified Petitioner that the reassignment application was incomplete, due to missing electronic signatures that “must be completed in order to complete the application.”  CMS Ex. 5, at 1.  The letter warned that Noridian “may reject your application(s) if you do not furnish complete information within 30 calendar days of the initial request.”  CMS. Ex. 5, at 1 (citing 42 C.F.R. § 424.525).  Petitioner did not respond to Noridian’s letter within 30 days of the initial request.  CMS Ex. 1, at 2.

On February 25, 2019, Noridian notified Petitioner that it was rejecting Petitioner’s applications due to the failure to complete the electronic signatures necessary to complete the reassignment application.  CMS Ex. 4, at 1 (“The electronic signatures on the 855R application for . . . Timothy Ekhlassi were not completed.”).

Petitioner filed new Medicare enrollment and reassignment applications on March 4, 2019.  CMS Ex. 1, at 2.  On April 16, 2019, Noridian notified Petitioner that the applications submitted on March 4, 2019, were approved and assigned an “effective date” of February 2, 2019.  CMS Ex. 3, at 1.

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Petitioner requested reconsideration, seeking an effective date of December 1, 2018.  CMS Ex. 2, at 5-6.  Petitioner argued that the practice manager had shown “due diligence” in completing the application process and claimed that Noridian erred in rejecting the November 15, 2018 applications that had the “required signatures.”  Id. at 5.  Petitioner submitted a printout of the “Manage Signatures” page in PECOS that shows available signature methods for Petitioner to either electronically sign or upload a signature.  Id. at 3.  Petitioner also submitted a printout of the “Electronic Signature Status” page in PECOS showing that a file entitled “Timothy Eklhassi [sic] MD signed Medicare documents.pdf” had been uploaded on November 15, 2018.  Id. at 7.

On July 18, 2019, Noridian issued an unfavorable reconsidered determination.  CMS Ex. 1.  Noridian confirmed that Petitioner’s November 15, 2018 enrollment and reassignment applications were rejected because the reassignment application did not contain the required signatures.  Id. at 3.  Noridian concluded that Petitioner’s “signature upload record” failed to show that a signature certification statement was uploaded.  Id.  Noridian confirmed that it received from Petitioner on March 4, 2019, new enrollment and reassignment applications that Noridian subsequently approved.  Id.  Noridian determined, consistent with section 424.520(d), that the effective date of Petitioner’s enrollment was March 4, 2019.  Id.  Noridian made clear that Petitioner was permitted to bill for services beginning February 2, 2019, in accordance with 42 C.F.R. § 424.521, which permits, in certain circumstances, retrospective billing for up to 30 days before the supplier’s effective date.  Id.

Petitioner timely requested an ALJ hearing.  Petitioner requested that his “effective date of enrollment in Medicare Part B be retro-dated to December 1, 2018.”  Request for Hearing (RFH) at 1.  Petitioner argued that his practice’s office manager made multiple telephone inquiries to Noridian staff “to assure that the documents had uploaded properly” and that “not once did any member of the Enrollment Team alert [Petitioner] that the application would not survive the process.”  Id.  Petitioner claimed that the practice manager “was assured that the representative could see the signatures and was told to allow the process to complete its course.”  Id.  Petitioner stated that he “began seeing Medicare patients at our clinic on December 5, 2018, with [the practice manager’s] assurance that the Enrollment process was underway and that [the practice manager] had confidence that [Petitioner’s] claims would be processed and paid.”  Id. at 2.

CMS filed a motion for summary judgment arguing that: (1) the rejection of Petitioner’s November 15, 2018 applications was not appealable, and (2) CMS provided Petitioner with the earliest effective date of billing privileges under the applicable regulations.  CMS Mot. for Summ. J. and Incorporated Mem. at 5-7.

The ALJ sustained Noridian’s reconsidered determination that March 4, 2019, was the correct effective date for Petitioner’s enrollment.  ALJ Decision at 1.  The ALJ admitted

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CMS’s exhibits into the record and acknowledged that Petitioner relied on his initial submissions (the request for reconsideration and the request for hearing).  Id. at 2.  Because neither party submitted written direct testimony of a witness, the ALJ determined an in-person hearing was unnecessary and decided the case based on the written record.  Id. at 2.  The ALJ concluded, based on 42 C.F.R. § 424.520(d), that Petitioner’s effective date of enrollment was March 4, 2019 because that was the date Petitioner filed the enrollment applications that were subsequently approved.  Id. at 2-3.5   The ALJ further concluded that she had no authority to review the rejection of Petitioner’s November 2018 applications.  Id. at 4.  Finally, the ALJ determined that she could not “grant Petitioner an earlier effective date based on any equitable or policy arguments.”  Id. (citing Howard M. Sokoloff, DPM, MS, Inc., DAB No. 2972, at 9 (2019)).

Petitioner timely filed a request for review of the ALJ Decision, reiterating many of the same arguments made before the ALJ.  Request for Review (RR) at 1.  Petitioner requests that the effective date of enrollment be changed to December 1, 2018, because Petitioner claims to have been “provided with erroneous information” about the applications during telephone conversations with Noridian representatives.  Id.  Petitioner also contends that his practice manager did not receive Noridian’s January 25, 2019 email regarding the missing signatures in the November 2018 reassignment application.  Id.

CMS filed a response brief arguing that the ALJ Decision is both supported by substantial evidence and free from legal error.  CMS Br. at 6.  CMS contends that the ALJ correctly concluded that March 4, 2019, was the effective date for billing privileges.  Id. at 5.  CMS asserts that the rejection of Petitioner’s November 2018 applications is not reviewable, and even if it were, “the rejection was properly determined” as Petitioner submitted “no evidence that the required signatures for the CMS-855R application were submitted.”  Id. at 5-6.

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Standard of Review

The Board’s standard of review on a disputed factual issue is whether the ALJ decision is supported by substantial evidence; the standard of review on a disputed issue of law is whether the ALJ’s decision is erroneous.  Guidelines – Appellate Review of Decisions of Administrative Law Judges Affecting a Provider’s or Supplier’s Enrollment in the Medicare Program (Guidelines), accessible at https://www.hhs.gov/about/agencies/dab/different-appeals-at-dab/appeals-to-board/guidelines/enrollment/index.html?language=en.

Analysis

I.  The ALJ’s conclusion that the effective date of Petitioner’s Medicare enrollment and billing privileges is March 4, 2019, is supported by substantial evidence and free of legal error.

The regulation at section 424.520(d) provides that the effective date of billing privileges is the later of either the date on which the enrollment application that was approved was filed with (that is, received by) a Medicare Administrative Contractor, or the date on which the supplier first began providing services at a new practice location.  Lakhanpal at 6 (citing 42 C.F.R. § 424.520(d)).  Petitioner does not dispute that the only enrollment and reassignment applications he filed that Noridian subsequently approved were the applications Noridian received on March 4, 2019.6   Thus, the effective date of Petitioner’s enrollment and billing privileges is March 4, 2019, the date that Noridian received Petitioner’s applications that were subsequently approved.  See, e.g., Frazer at 9 (concluding that the effective enrollment date was based on the date CMS received petitioner’s revalidation enrollment application that was “processed to approval”); Tosan Fregene, M.D. and Oncology Clinics, Inc., DAB No. 3018, at 6-7 (2020) (holding that the ALJ correctly determined the effective date for reactivation of petitioner’s billing privileges based on the “date of filing” of the enrollment application that was processed to approval); Yakup Akyol, M.D., DAB No. 3017, at 5-6 (2020) (determining the effective date of petitioner’s billing privileges based on the date that CMS received the first reassignment application that CMS was able to process to completion); Lakhanpal at 6-7 (holding that CMS (and subsequently the ALJ) had lawfully set the effective date of the physician’s reassignment and effective date of Medicare billing privileges based on the only reassignment application that was processed to approval).

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Section 424.521(a) provides, in relevant part, that a supplier whose enrollment application has been approved “may retrospectively bill for services” when the supplier “has met all program requirements” and “services were provided at the enrolled practice location for up to” “[t]hirty days prior to the[] effective date if circumstances precluded enrollment in advance of providing services to Medicare beneficiaries.”  42 C.F.R. § 424.521(a).  Accordingly, CMS allowed Petitioner to retrospectively bill for services beginning February 2, 2019, 30 days before the effective date of enrollment.  ALJ Decision at 3; CMS Ex. 1, at 3.

Petitioner identifies no error in the ALJ’s conclusion based on 42 C.F.R. § 424.520(d) that March 4, 2019 is “the correct effective date of enrollment.”  See ALJ Decision at 3.  Petitioner does not argue that the ALJ incorrectly cited or applied section 424.520(d).  Petitioner does not dispute that Noridian rejected his November 15, 2018 enrollment and reassignment applications.  See ALJ Decision at 4.  Petitioner also does not dispute that the enrollment and reassignment applications that Noridian approved were the applications filed on March 4, 2019.  See id.at 3.  Thus, based on the applicable legal authority, evidence, and undisputed facts, the ALJ’s conclusion that March 4, 2019 is the effective date of Petitioner’s Medicare enrollment and billing privileges is supported by substantial evidence and legally correct.

In his Request for Review, Petitioner raises various arguments challenging the rejection of his November 2018 enrollment application and reassignment application.  However, as we have discussed, the effective date of enrollment is determined solely based on the filing date of Petitioner’s second enrollment and reassignment applications because those were the only applications Noridian approved.  See 42 C.F.R. § 424.520(d).  Thus, any factual disputes Petitioner has raised, such as whether Petitioner indeed submitted the required signatures in his rejected November 2018 applications and whether Noridian representatives informed the practice manager of any deficiencies during telephone calls, are immaterial here as they do not affect the determination of the effective date of Petitioner’s enrollment.  Moreover, as we explain further below, neither the ALJ nor the Board has authority to review the rejection of Petitioner’s November 2018 applications.

II.  The ALJ correctly concluded she did not have authority to review the rejection of Petitioner’s November 2018 enrollment and reassignment applications.

In the request for review, Petitioner seeks an effective date of December 1, 2018, based on the rejected November 15, 2018 enrollment and reassignment applications.  RR at 1.  Petitioner asserts his practice manager did not receive Noridian’s January 25, 2019 email requesting additional information.  Id.  Petitioner further asserts that the practice manager “showed due diligence in completing the electronic application process which included appropriate signature uploads.”  Id.  He claims that, although his practice manager “followed up with multiple telephone calls to Noridian . . . to check on the status of the

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enrollment application,” Noridian’s representatives “never informed [the practice manager] of any deficiencies in [Petitioner’s] enrollment application.”  Id.

The rejection of a supplier’s enrollment application or reassignment application is not an “initial determination” subject to review by an ALJ or the Board under 42 C.F.R. § 498.3(b).  As explained earlier, the regulations governing these proceedings list the types of “initial determinations by CMS” that a Medicare supplier may appeal to an ALJ (including certain contractor or CMS reconsidered determinations).  See 42 C.F.R. § 498.3(b).  That list does not include the rejection of either a supplier’s enrollment application or its reassignment application.  Id.  Indeed, the enrollment regulations explicitly state that “[e]nrollment applications that are rejected are not afforded appeal rights.”  Id. § 424.525(d).  Moreover, the Board has consistently rejected arguments premised on the Board’s review of a rejected application.  See Lakhanpal at 7 (explaining that petitioner’s challenge to the rejection of his initial reassignment application is “impermissible in this forum” because the regulations provide that rejected enrollment applications are not afforded appeal rights); Wishon Radiological Med. Grp. at 8 (“There is . . . no applicable authority allowing a supplier to seek review of an unappealable rejection of an incomplete application by the ‘back door’ route of challenging the effective date of a later application which was processed to approval.”); Lindsay Zamis, M.D., a Prof’l Corp., DAB No. 2802, at 9-10 (2017) (“Neither the ALJ nor the Board has the authority to overturn [a Medicare contractor’s] determination to reject an enrollment application because the processing of an enrollment application . . .  did not go as the applicant expected or preferred.”); Shepard at 7-8 (explaining that petitioner’s arguments based on the alleged mishandling of an enrollment application was an indirect or backdoor challenge to an application rejection for which there are no administrative appeal rights).

“Although a supplier may appeal the denial of an enrollment application for cause, e.g., non-compliance with enrollment requirements, disqualifying felony criminal convictions, or providing false or misleading information, the regulations do not provide such appeal rights to suppliers whose applications are merely rejected for failing to timely submit complete information or documentation.”  Frazer at 10-11 (citing Chaplin Liu, M.D., DAB No. 2976, at 7 (2019) (citing 42 C.F.R. §§ 424.525, 424.530)).  Here, the ALJ determined that section 424.525(d) of the regulations prohibited her from reviewing Petitioner’s rejected applications.  ALJ Decision at 4.  The only determination the ALJ had authority to review was the effective date of Petitioner’s enrollment.  See 42 C.F.R. § 498.3(b)(15).  The Board has long held that, in reviewing the effective date of enrollment, to consider arguments that a contractor improperly rejected an earlier enrollment application would “ma[ke] a nullity” of the prohibition of appeals relating to rejected applications.  Zamis at 9 (citing Karthik Ramaswamy, M.D., DAB No. 2563 (2014), aff’d, Ramaswamy v. Burwell, 83 F. Supp. 3d 845 (E.D. Mo. 2015)); Shepard at 8.

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Thus, the ALJ did not err in concluding that she lacked authority to review the rejection of Petitioner’s November 2018 enrollment and reassignment applications.  Likewise, the Board has no authority to review the rejection, and we cannot entertain Petitioner’s arguments challenging that action.

III.  The ALJ correctly rejected Petitioner’s arguments based on equitable grounds.

To the extent that Petitioner renews the equitable arguments he made before the ALJ by asserting his practice manager did not receive Noridian’s January 25, 2019 email and Noridian did not notify Petitioner’s practice manager of any application deficiencies during telephone conversations, we reject them.  The Board has repeatedly held that it and ALJs are bound by the applicable regulations and cannot alter an effective date based on principles of equity.  See, e.g., Shepard at 9 (quoting Vijendra Dave, M.D., DAB No. 2672, at 8 (2016) and citing Cent. Kan. Cancer Inst., DAB No. 2749, at 10 (2016), appeal dismissed, Cent. Kan. Cancer Inst. v. Dep’t of Health & Human Servs., No. 2:17- cv-02012 (D. Kan. June 2, 2017) (The Board “is bound by the regulations, and may not choose to overturn the agency’s lawful use of its regulatory authority based on principles of equity.”)); Decatur Health Imaging, LLC, DAB No. 2805, at 11 (2017) (“Equitable considerations . . . provide no basis to . . . assign an earlier effective date.”).  Here, the applicable authority compels an effective date of enrollment of March 4, 2019, and we may not adjust that date based on equitable grounds.

Petitioner also appears to assert an equitable estoppel argument by stating that the practice manager was not informed during telephone calls with Noridian of any deficiencies in the enrollment and reassignment applications.  However, even if Petitioner could show that Noridian representatives provided false information or guidance in telephone conversations with Petitioner’s practice manager, and we do not conclude that Petitioner has done so, Petitioner has failed to show that Noridian “engaged in ‘affirmative misconduct,’ which is something more than failing to provide accurate information or negligently dispensing erroneous advice.”  Frazer at 12 (citing Linda Silva, P.A., DAB No. 2966, at 8 n.6 (2019)).  “[E]rroneous oral advice is inadequate, as a matter of law, to estop the government from enforcing federal law.”  Frazer at 12 (citing Wash. State Dept. of Soc. & Health Servs., DAB No. 1561, at 10 (1996)).

For these reasons, we reject Petitioner’s equitable arguments and sustain the ALJ’s decision declining to grant Petitioner an earlier effective date based on equitable grounds.  ALJ Decision at 4 (citing Sokoloff at 9).

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Conclusion

We affirm the ALJ Decision upholding Noridian’s determination that the effective date of Petitioner’s Medicare enrollment and billing privileges is March 4, 2019.

1.  We cite to, and apply, the enrollment regulations in effect on April 16, 2019, the date CMS’s contractor issued the initial determination regarding the effective date of Petitioner’s billing privileges.  See George Yaplee Med. Ctr. d/b/a Triangle Eye Inst., DAB No. 3003, at 3 n.3 (2020).  Although none apply to this appeal and do not affect our analysis, CMS subsequently published several revisions of the regulations governing Medicare enrollment and billing privileges.  See, e.g., 86 Fed. Reg. 62,240, 62,357 (Nov. 9, 2021) (adding 42 C.F.R. § 424.522 “Additional Effective Dates” which specifies that a “reassignment of benefits under § 424.80 is effective beginning 30 days before the Form CMS–855R is submitted if all applicable requirements during that period were otherwise met” and revising 42 C.F.R. § 424.525(a) to include ten rejection scenarios for rejecting an enrollment application).
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2.  PECOS is a web-based electronic enrollment process established under OMB System of Records Number (SORN) 09-70-0532.  66 Fed. Reg. 51,961-51,966 (Oct. 11, 2001); see also 71 Fed. Reg. 60,536-60,540 (Oct. 13, 2006).  A provider or supplier may use PECOS to apply to enroll in Medicare or make changes to its enrollment information.  42 C.F.R. § 424.502 (definition of “enrollment application”).
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3.  The factual information in this section is drawn from the ALJ Decision and the record and is not intended to replace, modify, or supplement the ALJ’s findings of fact.
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4.  Neither Petitioner nor CMS offered copies of the CMS-855I or CMS-855R applications as evidentiary exhibits before the ALJ.  Having considered the entire administrative record before us, including the pleadings and arguments, we have concluded that a full and fair review of this appeal can be conducted without the applications being admitted into evidence.  The issues on appeal revolve around the date of filing and the date the applications were approved and not around the content of the applications themselves.  Moreover, there is no dispute over the content of the applications which were subsequently approved by the CMS contractor.
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5.  Noridian is ambiguous about which applications it addressed in its initial and reconsidered determinations.  In the initial determination, Noridian stated that Petitioner’s “reassignment of benefits is approved” with no mention of the enrollment application.  CMS Ex. 3, at 1.  Further complicating matters, Petitioner’s request for reconsideration asked only that Noridian reconsider the effective date, without specifying between the enrollment and reassignment applications.  CMS Ex. 2, at 4.  In its reconsidered determination, Noridian noted that, “[o]n March 4, 2019, Noridian received a CMS 855I to enroll [Petitioner] into the Medicare program and an 855R to reassign his benefits to Bellingham Bay Ophthalmology LLC” that were subsequently approved, but also stated that Petitioner was seeking an earlier effective date of the reassignment.  CMS. Ex. 1, at 2-3.  In his request for Board review, Petitioner addresses only the effective date of enrollment.  RR at 1 (“I respectfully disagree with the Administrative Law Judge’s conclusion that March 4, 2019 is the effective date of enrollment.”).  Despite these communication lapses, neither party charges error in the ALJ’s decision to review the effective date of Petitioner’s enrollment (and not specifically the reassignment).  However, we read the ALJ’s decision as determining the effective date of both Petitioner’s enrollment and reassignment of benefits.  The applications were filed on the same date, March 4, 2019, and the parties appear to agree that the effective date of enrollment in connection with both applications is at issue now before the Board.  See Request for Review at 1; CMS Br. at 5-6.
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6.  Petitioner asserts he began providing services at the practice clinic on December 5, 2018.  RFH at 2.  However, Petitioner fails to explain how providing services on December 5, 2018 justifies an effective date of enrollment and reassignment of benefits of December 1, 2018.  Petitioner cites no authority supporting the derivation of an effective date of December 1, 2018 and has asserted merely that the practice manager assured Petitioner that claims for services he furnished to Medicare beneficiaries between December 5, 2018 and February 2, 2019 would be processed and paid.  See RFH at 2.
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