Derek Shadid, M.D. and Shadid Plastic Surgery Associates, DAB CR5613 (2020)

DECISION

The Centers for Medicare & Medicaid Services (CMS), through a CMS contractor, deactivated the Medicare billing privileges of Derek Shadid, M.D., and his medical practice, Shadid Plastic Surgery Associates (Surgery Associates) (together, Petitioners) effective July 18, 2018, because they failed to revalidate their Medicare enrollments.  The contractor later revalidated/reactivated Petitioners' billing privileges effective December 17, 2018, indicating Petitioners had a gap in billing privileges from July 17, 2018, through December 16, 2018.  On reconsideration, the contractor upheld a revalidation/reactivation effective date of December 17, 2018.

Petitioners requested a hearing to dispute the gap in their ability to bill Medicare.  The narrow issue over which I have authority in this case is to decide the effective date of the revalidation/reactivation of Petitioners' Medicare billing privileges.  The effective date of

Page 2

revalidation/reactivation is governed by the date the contractor received the enrollment application that it processed to completion.

Based on the record, I conclude that the contractor received Petitioners' revalidation enrollment application on November 30, 2018, and ultimately processed that application to approval.  Therefore, the effective date of revalidation/reactivation is November 30, 2018.  Further, I note that according to the deactivation notice, the deactivation commenced on July 18, 2018, and not July 17, 2018.  Consequently, there is a gap in Petitioners' billing privileges from July 18, 2018, through November 29, 2018.

I.  Background and Procedural History

Dr. Shadid enrolled in the Medicare program as a supplier in 2005, and his practice enrolled as a supplier in 2002.  See CMS Exhibit (Ex.) 1 at 1; CMS Ex. 15 at 1-2.

In a March 9, 2018 letter, the CMS contractor notified Dr. Shadid that he needed to revalidate his Medicare enrollment by May 31, 2018, either online through CMS's Provider Enrollment, Chain, and Ownership System (PECOS), or by submitting a form CMS-855 enrollment application.  CMS Ex. 2.  The notice warned that if the contractor did not receive a response, the contractor may deactivate Dr. Shadid's Medicare billing privileges, in which event he would "not be paid for services rendered during the period of deactivation.  This will cause a gap in [his] reimbursement."  CMS Ex. 2 at 1.

Although the March 9, 2018 notice stated Dr. Shadid had until May 31, 2018, to revalidate, the contractor sent another letter, dated April 11, 2018, stating that he had "not revalidated by the requested due date of November 07, 2017."  CMS Ex. 3 at 1.1

In response to this notice, Dr. Shadid submitted a form CMS-855I enrollment application to revalidate his enrollment, which the contractor received on April 30, 2018.  CMS Ex. 4.  In a May 19, 2018 letter, the contractor acknowledged receipt of the revalidation enrollment application, but informed Dr. Shadid that he needed to provide additional information so that the contractor could complete the processing of his application.  CMS Ex. 5.  The notice stated that the contractor may reject the application if Dr. Shadid did not provide the information within 30 days.  CMS Ex. 5 at 1.

In response, on June 18, 2018, Dr. Shadid's office faxed to the contractor a form CMS-855B.  CMS Ex. 6.  Whereas the CMS-855I form (the form used for enrollment by physicians and certain non-physician practitioners) the contractor received on April 30, 2018, identified Dr. Shadid, the June 18, 2018 CMS-855B form (used to enroll clinics,

Page 3

group practices, and certain other suppliers) identified Shadid Plastic Surgery Associates.  Compare CMS Ex. 4 at 7 with CMS Ex. 6 at 17.

The CMS contractor treated the June 18, 2018 CMS-855B form as an application to revalidate the Medicare enrollment of both Petitioners (i.e., Shadid, M.D., and Surgery Associates) and, by letter dated July 17, 2018, informed Petitioners that it had rejected the revalidation application on the grounds that they had not timely submitted documentation the contractor had requested.  CMS Ex. 7.  The deactivation notice stated that Petitioners' Medicare billing privileges would be deactivated on July 18, 2018, and, to revalidate, Petitioners would have to submit a new Medicare enrollment application through PECOS or through a CMS-855I form.2  CMS Ex. 7 at 1.

It appears that on September 24, 2018, the CMS contractor received a second CMS-855I revalidation enrollment application from Petitioners.3  CMS Ex. 8.  By letter dated October 10, 2018, the contractor requested additional information from Petitioners.  CMS Ex. 18.  Petitioners responded with additional information via fax on October 30, 2018, and through mail received by the contractor on November 6, 2018.4  CMS Exs. 9, 10.  By letter dated November 21, 2018, the contractor rejected Petitioners' September 24, 2018 revalidation application.  CMS Ex. 11.

Petitioners then filed another revalidation application, which CMS's contractor received on November 30, 2018.  CMS Ex. 12 at 69 (envelope date stamped "NOV 30, 2018); see also CMS Ex. 12 at 1-69 (each page stamped with Julian Date Calendar numbers "18" and "334", corresponding to the 334th day of 2018, or November 30, 2018).  By letter dated December 7, 2018, the contractor identified the need for additional information, including a certification statement located in section 15 of the CMS-855I form.  CMS Ex. 13; see CMS Ex. 12 at 57.  Petitioners responded with the requested information, including a signed certification statement, on December 17, 2018.  CMS Ex. 14 at 59 (envelope date stamped DEC 17, 2018); see also CMS Ex. 14 at 1-59 (each page stamped

Page 4

with Julian Date Calendar numbers "18" and "351," likely corresponding to December 17, 2018).

The CMS contractor processed the application to completion and, on January 10, 2019, issued an initial determination approving Petitioners' revalidation enrollment application, but stated that Petitioners "will have a gap in billing privileges from July 17, 2018 through December 16, 2018 for failing to respond to a development request related to a revalidation application."  CMS Ex. 15 at 1.

Petitioners requested reconsideration and, in a reconsidered determination dated March 18, 2019, the contractor upheld its initial determination and the corresponding gap in billing privileges.  CMS Exs. 16, 17.  The CMS contractor stated that it had received a CMS-855I revalidation enrollment application on November 30, 2018, issued a development request for more information including a certification statement on December 7, 2018, and received a response to the development request on December 17, 2018.  The contractor recounted Petitioners' assertion that, in response to a June 25, 2018 phone call from a contractor's representative, they emailed the requested information, including a certification statement, to the contractor.  However, the contractor stated it had "no receipt of an email dated June 25, 2018 containing a development response" and, thus, upheld the December 17, 2018 effective date.  CMS Ex. 17 at 3.

Petitioners timely requested a hearing on April 2, 2019.  Hearing Request.  On April 4, 2019, I issued an Acknowledgment and Prehearing Order (Prehearing Order), which established a schedule for prehearing exchanges.  CMS subsequently filed a brief (CMS Br.) and 18 exhibits (CMS Exs. 1-18).  Petitioners then filed a brief (P. Br.) and three exhibits (P. Exs. 1-3).

II.  Decision on the Written Record

I admit CMS Exs. 1-18 and P. Exs 1-3 without objection.  Prehearing Order ¶ 7; Civil Remedies Division Procedures (CRDP) § 14(e).

The Prehearing Order advised the parties to submit written direct testimony for each witness and that an in-person hearing would only be held if a party requested to cross-examine a witness.  Prehearing Order ¶¶ 8-10; CRDP §§ 16(b), 19(b).  The parties have not offered any written direct testimony.  Therefore, I issue this decision based on the written record.  Prehearing Order ¶¶ 10-11; CRDP § 19(d).

Page 5

III.  Issue

Whether CMS correctly assigned December 17, 2018, as the effective date for the reactivation of Petitioners' Medicare billing privileges.

IV.  Jurisdiction

I have jurisdiction to hear and decide this case.  42 C.F.R §§ 498.3(b)(15), 498.5(l)(2); see also 42 U.S.C. § 1395cc(j)(8).

V.  Findings of Fact, Conclusions of Law, and Analysis

My findings of fact and conclusions of law are set forth in italics and bold font.

The Social Security Act (Act) authorizes the Secretary of Health and Human Services (Secretary) to promulgate regulations governing the enrollment process for providers and suppliers.  42 U.S.C. §§ 1302, 1395cc(j).  A "supplier" is "a physician or other practitioner, a facility, or other entity (other than a provider of services) that furnishes items or services" under the Medicare provisions of the Act.  42 U.S.C. § 1395x(d); see also 42 U.S.C. § 1395x(u).

A supplier must enroll in the Medicare program to receive payment for covered Medicare items or services.  42 C.F.R. § 424.505.  The term "Enroll/Enrollment means the process that Medicare uses to establish eligibility to submit claims for Medicare covered items and services."  42 C.F.R. § 424.502.  A supplier seeking billing privileges under the Medicare program must "submit enrollment information on the applicable enrollment application.  Once the . . . supplier successfully completes the enrollment process . . . CMS enrolls the . . . supplier into the Medicare program."  42 C.F.R. § 424.510(a).  On the enrollment application, the certification statement must be signed by an individual who has authority to legally and financially bind the supplier.  42 C.F.R. § 424.510(d)(3).  When CMS enrolls a supplier, CMS establishes an effective date for billing privileges and may permit limited retrospective billing.  42 C.F.R. §§ 424.510(b), 424.520, 424.521.

To maintain Medicare billing privileges, suppliers must revalidate their enrollment information at least every five years; however, CMS reserves the right to require revalidation at any time.  When CMS notifies a supplier that it is time to revalidate, the supplier must submit a signed enrollment application, accurate information, and supporting documents within 60 calendar days of CMS's notification.  42 C.F.R. § 424.515.

CMS may reject an enrollment application.  It may do so immediately if the supplier fails to provide the application fee or a request for waiver of that fee.  42 C.F.R. §§ 424.514(g)(1), 424.525(a)(3).  However, if a supplier fails to furnish complete

Page 6

information on the enrollment application or furnish all supporting documentation, CMS may only reject an enrollment application after the supplier has been given 30 days to provide the necessary information or documentation.  42 C.F.R. § 424.525(a)(1)-(2).

CMS can also deactivate an enrolled supplier's Medicare billing privileges if the supplier fails to comply with revalidation requirements.  42 C.F.R. § 424.540(a)(3).  When CMS deactivates a supplier's Medicare billing privileges, "[n]o payment may be made for otherwise Medicare covered items or services furnished to a Medicare beneficiary."  42 C.F.R. § 424.555(b).  If CMS deactivates a supplier's billing privileges due to an untimely response to a revalidation request, the enrolled supplier may apply for CMS to reactivate its Medicare billing privileges by completing a new enrollment application or, if deemed appropriate, recertifying its enrollment information that is on file.  42 C.F.R. § 424.540(b)(1).

1. Petitioners were enrolled in the Medicare program as suppliers prior to 2018.  CMS Ex. 1 at 1; CMS Ex. 15 at 1-2.

2. The CMS contractor deactivated Petitioners' Medicare billing privileges effective July 18, 2018, because Petitioners did not file a revalidation enrollment application that the CMS contractor could approve.  CMS Ex. 7 at 1; see also CMS Ex. 5.

3. While still deactivated, Petitioners filed a CMS-855I enrollment application seeking to revalidate their Medicare enrollments, which CMS's contractor received on November 30, 2018.  CMS Ex. 12.

4. In a December 7, 2018 letter, the CMS contractor stated that it may reject Petitioners' revalidation enrollment application if Petitioners failed to furnish complete information within 30 days of the postmark on the letter.  CMS Ex. 13 at 1.

5. In the December 7, 2018 letter, the CMS contractor identified the information that Petitioners needed to supply in order to avoid rejection of the revalidation enrollment application, which included a signed certification statement.  CMS Ex. 13 at 1-2.

6. On December 17, 2018, Petitioners provided the requested information.  CMS Ex. 14.

7. The CMS contractor processed Petitioners' November 30, 2018 revalidation enrollment application to completion and reactivated Petitioners' Medicare enrollment effective December 17, 2018.  CMS Ex. 15.

Page 7

8. Because the CMS contractor never rejected Petitioners' revalidation enrollment application that was received on November 30, 2018, and subsequently approved that application, the effective date for the revalidation of enrollment and reactivation of billing privileges is November 30, 2018.  42 C.F.R. § 424.520(d).

In the present case, the CMS contractor, in both the initial and reconsidered determinations, indicated that the end of Petitioners' gap in Medicare billing privileges (i.e., the effective date of reactivation) was December 17, 2018.  CMS Ex. 15 at 1; CMS Ex. 17 at 3.  In the reconsidered determination, the CMS contractor stated that it received Petitioners' revalidation enrollment application on November 30, 2018, and that it received a "development response" on December 17, 2018.  CMS Ex. 17 at 3.

CMS contends December 17, 2018, is the correct effective date for reactivation of Petitioners' billing privileges.  CMS states that November 30, 2018, is the date the contractor "received another new revalidation application" (i.e., CMS Ex. 12) from Petitioners.  CMS further states:  "However, this application did not include a Section 15 certification statement.  On December 7, 2018, [the contractor] issued a development request, requesting additional information, including the Section 15 certification statement.  On December 17, 2018, a development response was received by [the contractor] and deemed complete."  CMS Br. at 4.  CMS asserts that December 17, 2018, is the effective date of Petitioners' revalidation of enrollment because, although the contractor received Petitioners' revalidation enrollment application on November 30, 2018, "[o]n December 17, 2018, a development response was received by [the contractor], and deemed complete."  CMS Br. at 7.  CMS further contends that pursuant to the Medicare Program Integrity Manual (MPIM), "the contractor should 'establish an effective date based on the receipt date of the [complete] application.'"  Id. (citing MPIM, Ch. 15, § 15.29.4.3 (Rev. 685, eff. Sept. 6, 2016)) (brackets in original).  Thus, CMS contends, the effective date of reactivation in this case is the date the contractor received the development response, December 17, 2018, at which time the contractor deemed the application "complete."  CMS Br. at 8-9.

Petitioners request that I find August 16, 2018, as the effective date of reactivation of billing privileges.  P. Br. at 2.  Petitioners state that, on June 25, 2018, they "submitted the requested documentation via email to CMS with all sections completed that were addressed in the Request for Additional Information Letter dated May 19, 2018.  No further correspondence was received from CMS until petitioner[s] began receiving claim denials in or around September 2018."  Petitioners state that "during this time" Dr. Shadid was told by a contractor's representative that "he could appeal the effective date of his contract to cover the treatment for his patients who had Medicare benefits.  It was felt that treatment should be continued because these were patients with an active diagnosis of cancer."  P. Br. at 1.

I conclude that neither of the parties' arguments is entirely correct.

Page 8

Under the governing regulations, the effective date of enrollment (or revalidation of enrollment) is the date of filing of the revalidation enrollment application (i.e., the form CMS-855 or the electronic counterpart in PECOS), so long as the CMS contractor continues to process that application and ultimately approves it, not the date that the contractor receives a response to a development request regarding the application.  42 C.F.R. §§ 424.502 (definition of Enrollment application); 424.520(d) (the effective date for billing privileges for physician organizations is the date of filing of an enrollment application that is subsequently approved); 424.525(a)(2) (CMS must give suppliers 30 days to provide missing information from their enrollment applications before CMS can reject those applications).

The evidence in the record shows that the CMS contractor:  1) received a revalidation enrollment application from Petitioners on November 30, 2018; 2) acknowledged receipt of that revalidation enrollment application; 3) notified Petitioners that it may reject the revalidation enrollment application if Petitioners did not provide additional information, including a signed certification statement, within 30 days; 4) received all the necessary information from Petitioners, including the signed certification statement, in a timely manner; 5) never rejected Petitioners' revalidation enrollment application received on November 30, 2018; and 6) approved Petitioners' revalidation enrollment application received on November 30, 2018.  Because the CMS contractor never rejected the revalidation enrollment application, but subsequently approved it after timely receiving the requested information from Petitioners, the effective date for the revalidation and reactivation is November 30, 2018.

Although not clearly argued, the CMS contractor may have assigned a later effective date based on the fact that the application had been missing a certification statement.  This does not alter the analysis in this case.  See CheunJu Chen, M.D., DAB CR5465 at 4-8 (2019) (providing detailed discussion on this issue, which I find persuasive and adopt).  As the Departmental Appeals Board (DAB) interpreted the regulations in the context of a missing signature on an enrollment application:

Prior to the effective date of the amended section 424.520(d), neither the regulations nor their preamble directly addressed this question.  As explained below, we conclude that, at the very least, a missing signature fell within the scope of section 424.525.

Section 424.525 specifically provides that an applicant will have at least 30 days to provide any missing information or supporting documentation before a contractor may reject an application.  As noted above, the preamble indicated that an application would not be rejected if the applicant was actively communicating with contractor. . . .  Thus, the regulations in

Page 9

effect at the time of the November 2008 application created a process in which a contractor was able to subsequently approve an application even if it was not signed and fully complete when it was first submitted.  Neither regulation [section 424.525 or section 424.530] treated a missing signature as different from other information or documentation to be handled through that process.

Tri-Valley Family Med., Inc., DAB No. 2358 at 8 (2010).  In Tri-Valley, the supplier filed the enrollment application just before the publication of a final rule modifying certain enrollment regulations.  In the preamble to that final rule, CMS responded to a public comment indicating that the date of filing of an enrollment application is the date of receipt of a signed enrollment application.  73 Fed. Reg. 69,726, 69,769 (Nov. 19, 2008).  Because the hearing level decision used that preamble language in its analysis, the DAB explained, in regard to its discussion quoted at length above, that the "amended regulations do not alter the process established by sections 424.525 and 424.530.  Thus, even after the amended regulation became effective, an application need not be fully complete at the time of submission to be processed to approval."  Tri-Valley, DAB No. 2358 at 8 n.6.5  Therefore, Tri-Valley simply acknowledges that it is the regulatory text itself that has the force of law and not statements made in response to public comments.  See Chrysler Corp. v. Brown, 441 U.S. 281, 295 (1979).  Had the Secretary intended to treat enrollment applications without a signed certification statement differently than other incomplete applications, the Secretary would have changed the regulatory text when publishing the final rule in 2008.  However, the Secretary did not do this, leaving CMS with only two regulatory options to dispose of an enrollment application that it cannot approve:  denial of enrollment or rejection of the enrollment application.  42 C.F.R. §§ 424.525, 424.530; Tri-Valley, DAB No. 2358 at 8 ("the regulations authorize CMS only to reject or deny an enrollment application.").  The CMS contractor took neither of these actions with regard to the revalidation enrollment application filed on November 30, 2018.

In regard to CMS's argument and reliance on the MPIM, I note several problems with CMS's quotation of MPIM, Ch. 15, § 15.29.4.3 in its brief.  To start with, CMS quotes language from revision 685, which was effective September 6, 2016, but the version in effect on the date relevant here, November 30, 2018 (as well as on December 17, 2018), was revision 762, effective January 29, 2018.  See https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R762PI.pdf (last visited May 6, 2020).

Moreover, both the version CMS cited to, and the version in effect on the relevant date, stated simply that the effective date of revalidation would be "based on the receipt date of

Page 10

the application."  However, in quoting that section, CMS added, in brackets, the word "complete" prior to the word "application."  CMS Br. at 7.  CMS's modification changes the meaning of the quoted text in a manner that incorrectly assumes part of the ground in controversy in this case.  Because Petitioners submitted an application, and later submitted a signed certification (at which point the contractor deemed the application "complete"), part of the analysis in this case involves determining whether the effective date of Petitioners' revalidation is:  (1) the date the contractor received the application or; (2) the date it deemed the application complete.  By inserting, in brackets, the word "complete," CMS altered the quoted language in a way that indicates the latter (that the effective date is the date the contractor deemed the application complete), instead of the MPIM's plain language indicating the former (that the effective date is the date the contractor received the application).

Furthermore, it is unclear why CMS cited to MPIM, Ch. 15, § 15.29.4.3 in the first place.  Although that section refers to the conclusion of a gap period and, from that, one might infer the effective date of reactivation, the MPIM section that specifically pertains to the effective date of reactivation is found in MPIM, Ch.15, § 15.27.1.2 (Rev. 561, eff. Mar. 18, 2015).  That section states that "[i]f the contractor approves a provider or supplier's reactivation application or reactivation certification package (RCP) for a Part B non-certified supplier, the reactivation effective date shall be the date the contractor received the application or RCP that was processed to completion."

In any event, I find the MPIM does not have any authority to affect the outcome in this case.  Section 1871 of the Act requires all rules, requirements, and statements of policy that establish or change a substantive legal standard governing the scope of Medicare benefits, payment of services, or eligibility to furnish services or receive benefits to be promulgated through notice and comment rulemaking.  42 U.S.C. § 1395hh(a)(2).  This statute is significant because it more broadly requires the use of notice and comment rulemaking for Medicare policy than the Administrative Procedure Act does.  See Azar v. Allina, 139 S.Ct. 1804, 1810-14 (2019).  Therefore, only the regulatory text is binding.  As I indicated above, the regulatory text above directs an effective date of November 30, 2018.

Petitioners, however, request that I find the effective date of revalidation is instead August 16, 2018.  P. Br. at 2.  Dr. Shadid contends that his office responded to the contractor's requests for information with "all requested information" prior to filing the November 30, 2018 enrollment revalidation application.  P. Br. at 1.  Additionally, Petitioners assert that "this is information CMS has already had on file for several years."  Id.

Petitioners do not specifically explain, and it is not otherwise apparent from the record, why August 16, 2018, would be the correct effective date of reactivation in this case.  For example, there is no indication in the record, or contention from a party, that August 16,

Page 11

2018, was the day Petitioners sent, or the contractor received, any documentation such as an enrollment revalidation application.  I note, however, that Dr. Shadid stated in the hearing request that his office contacted the contractor "about being in the middle of treatment for a few of our patients who had active cancer and was told to proceed with treatment and we could request a retro[active] effective date to cover their surgeries."  Hearing Request.

To the extent Petitioners request retroactive billing privileges beginning August 16, 2018, based on treatment Dr. Shadid or his practice provided to Medicare beneficiaries on that (and any subsequent) dates, I have no authority to review a determination to grant or not grant retrospective billing because that is not an "initial determination" subject to ALJ review.  See 42 C.F.R. § 498.3(b).

Further, to the extent Petitioners request an earlier revalidation effective date based on the dates of treatment Dr. Shadid or his practice provided to Medicare beneficiaries, or based on information provided by a contractor representative, those are not reasons for which I may change Petitioners' effective date.  I do not have authority under the regulations to provide equitable relief based on principles of fairness or equitable estoppel.  US Ultrasound, DAB No. 2302 at 8 (2010) ("[n]either the ALJ nor the Board is authorized to provide equitable relief by reimbursing or enrolling a supplier who does not meet statutory or regulatory requirements.").

Finally, to the extent Petitioners request an earlier effective date of revalidation based on the applications they submitted prior to November 30, 2018, but which the CMS contractor rejected, I do not have the authority to review the decisions to reject Petitioners' prior revalidation applications.  CMS's (or its contractor's) rejection of an enrollment application is not subject to administrative review.  42 C.F.R. § 424.525(d).  Likewise, I do not have the authority to review the contractor's deactivation of Petitioners' Medicare billing privileges because deactivation is not an "initial determination" subject to appeal, and deactivation determinations have a separate review process involving the submission of a rebuttal to CMS.  See 42 C.F.R. §§ 424.545(b), 498.3(b); see also Willie Goffney, Jr., M.D., DAB No. 2763 at 4-5 (2017), aff'd sub nom. Goffney v. Azar,No. CV 17-8032 MRW (C.D. Cal. Sept. 25, 2019).

As stated above, I only have authority to decide the date of revalidation of enrollment and the reactivation of Petitioners' billing privileges based on the facts in this case and the law.  Ark. Health Grp., DAB No. 2929 at 12 (2019) ("Where, as here, the contractor deactivated Petitioners' billing privileges, the issue for us (and the ALJ) is the effective date of reactivation.").  In this case, the contractor received Petitioners' revalidation application on November 30, 2018, and ultimately approved that application.  CMS Ex. 12 at 69.  Therefore, November 30, 2018, is the effective date of Petitioners' enrollment revalidation and reactivation of billing privileges.  42 C.F.R. § 424.520(d).

Page 12

Consequently, there is a gap in Petitioners' billing privileges from July 18, 2018, through November 29, 2018.

VI.  Conclusion

The effective date for Petitioners' revalidation of enrollment, and for reactivation of Petitioners' billing privileges, is November 30, 2018.

• 1. The parties have not addressed the discrepancy in the revalidation due dates, but it appears the contractor inadvertently entered the wrong due date in its April 11, 2018 notice.
• 2. Presumably, the contractor rejected both the CMS-855I form it received on April 30, 2018, and the June 18, 2018 CMS-855B form.  However, separate notice(s) that the contractor had rejected the revalidation enrollment application(s) are not in the record; thus, the rejections must instead be inferred from the notice that Petitioners' billing privileges were being deactivated.
• 3. Each page in CMS Ex. 8 is stamped with a number beginning with "18" followed by "0924," likely denoting that the contractor received the application on September 24, 2018.
• 4. Additionally, each page in CMS Ex. 10 is stamped with Julian Date Calendar numbers "18" and "310," likely corresponding to the 310th day of 2018, or November 6, 2018
• 5. Although the DAB later questioned certain aspects of Tri-Valley, this did not affect the portions of it relevant to this case.  See Chen, DAB CR5465 at 7-8.