Page 24 - Medicare Benefit Policy Manual

• Prosthetics and orthotics
• Prosthetics devices
• Therapeutic shoes
• Surgical dressings and splint casts
• Drugs (A/B MAC (B) and DME MAC)
• Clinical laboratory services, and
• Ambulance services
• Screening and preventive services not already covered

See Pub. 100.04, chapter 19, Medicare Claims Processing Manual, for more information
on these benefits and the effective date for each of these benefits.

40 - Effect of Beneficiary Agreements Not to Use Medicare Coverage
(Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)

Normally physicians and practitioners are required to submit claims on behalf of
beneficiaries for all items and services they provide for which Medicare payment may be
made under Part B. Also, they are not allowed to charge beneficiaries in excess of the
limits on charges that apply to the item or service being furnished.

However, a physician or practitioner (as defined in §40.4) may opt out of Medicare. A
physician or practitioner who opts out is not required to submit claims on behalf of
beneficiaries and also is excluded from limits on charges for Medicare covered services.

Only physicians and practitioners that are listed in §40.4 may opt out.

• The only situation in which non-opt-out physicians or practitioners, or other
suppliers, are not required to submit claims to Medicare for covered services is
where a beneficiary or the beneficiary’s legal representative refuses, of his/her
own free will, to authorize the submission of a bill to Medicare. However, the
limits on what the physician, practitioner, or other supplier may collect from the
beneficiary continue to apply to charges for the covered service, notwithstanding
the absence of a claim to Medicare.

• In some circumstances, a non-opt-out physician/practitioner, or other supplier, is
required to provide an Advance Beneficiary Notice of Noncoverage (ABN) to the
beneficiary prior to rendering an item or service that is usually covered by
Medicare but may not be covered in this particular case. (See the Medicare
Claims Processing Manual, chapter 30 for ABN policy and §40.24 of this chapter
for a description of the difference between an ABN and a private contract.) The
ABN notifies the beneficiary that Medicare will likely deny the claim and
prompts the beneficiary to choose whether or not he/she will accept liability for
the full cost of the services if Medicare does not pay. The beneficiary also
indicates on the ABN whether or not a claim should be submitted to Medicare.
Providers and suppliers must follow the beneficiary’s directive for claim
submission as indicated on the ABN. Providers and suppliers will not violate the