Page 38 - Medicare Benefit Policy Manual

what the Medicare contractor considers to be a substantial number of claims submissions
by beneficiaries for items or services by an opt-out physician or practitioner, it must
investigate to ensure that contracts between the physician or practitioner and the
beneficiaries exist and that the terms of the contracts meet the Medicare statutory
requirements outlined in this instruction. If noncompliance with the opt-out affidavit is
determined, it must develop claims submission or limiting charge violation cases, as
appropriate, based on its findings.

In cases in which the beneficiary files an appeal of the denial of a beneficiary-filed claim
for services from an opt-out physician or practitioner, and alleges that there was no
private contract, the Medicare contractor must ask the physician/practitioner to provide it
with a copy of the private contract. Where the physician or practitioner does not provide
a copy of a private contract that meets the requirements of §40.8 and was signed by the
beneficiary before the service was furnished, the Medicare contractor must make
payment to the beneficiary and proceed as described above.

40.13 - Physician/Practitioner Who Has Never Enrolled in Medicare
(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)

For a physician/practitioner who has never enrolled in the Medicare program and wishes
to opt-out of Medicare, if the physician/practitioner does not have an NPI, then the
physician/practitioner must include his or her TIN on the opt-out affidavit. The Medicare
contractor must annotate its in-house provider file that the physician/practitioner has
opted out of the program. The Medicare contractor can get the full name, address, license
number, and tax identification number from the physician’s/practitioner’s opt-out
affidavit. All other data requirements should be developed from other data sources (e.g.,
the American Medical Association, State Licensing Board, etc.). The
physician/practitioner must not receive payment during the opt-out period (except in the
case of emergency or urgent care services). If the Medicare contractor needs additional
data elements and cannot obtain that information from another source, it may contact the
physician/practitioner directly. It must notify the physician or practitioner that in order to
certify or order services for a Medicare patient, the physician or practitioner must have a
valid NPI.

If an opt-out physician/practitioner provides emergency or urgent care service to a
beneficiary who has not signed a private contract with the physician or practitioner and
the physician/practitioner submits an assigned claim, the physician or practitioner must
complete Form CMS-855-I and enroll in the Medicare program before receiving
reimbursement. Under a similar circumstance, if the physician or practitioner submits an
unassigned claim, the Medicare contractor must pay the beneficiary directly without
requiring a completed Form CMS-855-I. It may use the information from the affidavit to
begin the enrollment process.

40.14 - Nonparticipating Physicians or Practitioners Who Opt Out of
Medicare
(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)