Page 28 - Medicare Benefit Policy Manual

Under the statute, the physician/practitioner cannot choose to opt-out of Medicare for
some Medicare beneficiaries but not others; or for some services but not others. The
physician/practitioner who chooses to opt-out of Medicare may provide covered care to
Medicare beneficiaries only through private contracts.

Medicare will make payment for covered, medically necessary services that are ordered
or certified by a physician/practitioner who has opted out of Medicare if the ordering or
certifying physician/practitioner has acquired a National Provider Identifier (NPI), reports
his/her Social Security Number, has a valid opt-out affidavit on file with his or her
Medicare Administrative Contractor (MAC), is of a specialty that is eligible to order and
certify, and provided that the services are not furnished by another physician/practitioner
who has also opted out. For example, if an opt-out physician/practitioner admits a
beneficiary to a hospital, Medicare will reimburse the hospital for medically necessary
care.

40.6 - When Payment May be Made to a Beneficiary for Service of an
Opt-Out Physician/Practitioner
(Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)

Payment may be made to a beneficiary for services of an opt out physician/practitioner in
two cases:

• The services are emergency or urgent care services furnished by an opt-out
physician/practitioner to a beneficiary with whom he/she has not previously entered into
a private contract. (See §40.28 for further discussion of emergency and urgent care
services by opt-out physicians and practitioners.); or

• The opt-out physician/practitioner failed to privately contract with the beneficiary
for services that he/she provided that were not emergency or urgent care services. The
CMS expects this case to come to the Medicare A/B MAC (B)’s attention as a result of a
complaint from a beneficiary or the beneficiary’s legal representative, or as a result of the
beneficiary or the beneficiary’s legal representative filing a claim for services furnished
by an opt out physician/practitioner. Medicare payment may be made for the claims
submitted by a beneficiary for the services of an opt out physician/practitioner when the
physician/practitioner did not privately contract with the beneficiary for services that
were not emergency care services or urgent care services and that were furnished no later
than 15 days after the date of a notice by the A/B MAC (B) that the physician/practitioner
has opted out of Medicare (see 42 CFR 405.435(c)). Therefore, if the beneficiary
submits a claim for a service that was furnished by an opt out physician/practitioner, then
the A/B MAC (B) must contact the opt out physician/practitioner in order to ascertain
whether the beneficiary entered into a private contract with the opt out
physician/practitioner. (Note: The A/B MAC (B) should obtain a copy of the private
contract from the opt out physician/practitioner before denying the beneficiary’s claim if
the beneficiary did, in fact, enter into a private contract with the physician/practitioner.)
If the beneficiary did not enter into a private contract with the physician/practitioner and
the beneficiary did not receive notice from the A/B MAC (B) that the