Page 39 - Medicare Benefit Policy Manual

A nonparticipating physician or practitioner may opt-out of Medicare at any time in
accordance with the following:

• The initial 2-year opt-out period begins the date the affidavit meeting the
requirements of §40.9 is signed, provided the affidavit is filed within 10 days
after the physician or practitioner signs his or her first private contract with a
Medicare beneficiary.

• If the physician or practitioner does not timely file any required affidavit, the
initial 2-year opt-out period begins when the last such affidavit is filed. Any
private contract entered into before the last required affidavit is filed becomes
effective upon the filing of the last required affidavit and the furnishing of any
items or services to a Medicare beneficiary under such contract before the last
required affidavit is filed is subject to standard Medicare rules.

40.15 - Excluded Physicians and Practitioners
(Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)

An excluded physician or practitioner may opt out of Medicare by submitting the
required documentation in accordance with §40.9. When determining effective dates of
the exclusion versus the opt-out, the date of exclusion always takes precedence over the
date the physician or practitioner opts out of Medicare. A physician or practitioner who
has been excluded must comply with 42 CFR 1001.1901, “Scope and Effect of
Exclusion.”

If an excluded/opt-out physician or practitioner submits a claim to Medicare, the
Medicare contractor must not make payment for services furnished, ordered, or
prescribed on or after the effective date of the exclusion, except in the limited
circumstances stated in 42 CFR 1001.1901.

The Medicare contractor must not make payment to a beneficiary who submits claims for
services rendered by an excluded/opt-out physician or practitioner (except where
payment would otherwise be made in accordance with the Medicare Program Integrity
Manual). It must deny the claim and send the physician or practitioner the appropriate
remittance and send the beneficiary a MSN as explained in §40.39.

40.16 - Relationship Between Opt-Out and Medicare Participation
Agreements
(Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)

Participation agreements will terminate on the opt out effective date. See 40.17 for
effective date provisions. Physicians and practitioners may not provide services under
private contracts with beneficiaries earlier than the effective date of the affidavit.
Nonparticipating physicians and practitioners may opt out at any time.