Page 44 - Medicare Benefit Policy Manual

40.26 - Registration and Identification of Physicians or Practitioners
Who Opt Out
(Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)

If the Medicare contractor has the physician’s/practitioner’s NPI, then the Medicare
contractor should use it in order to identify opt-out physicians or practitioners
nationwide. However, if the physician/practitioner does not have an NPI, then the
Medicare contractor must use the physician’s or practitioner’s TIN to identify opt-out
physicians or practitioners nationwide.

40.27 - System Identification
(Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)

The Medicare contractor must ensure that its system can automatically identify claims
that include services furnished by providers or practitioners who have opted out of
Medicare. It must not make payment to any opt-out physician/practitioner for items or
services furnished on or after the effective date of the physician’s or practitioner’s opt out
affidavit unless there are emergency or urgent care situations involved. In an emergency
or urgent care situation, payment can be made for services furnished to a Medicare
beneficiary if the beneficiary has no contract with the opt-out physician/practitioner. See
the following section for related instructions.

40.28 - Emergency and Urgent Care Situations
(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)

Payment may be made for services furnished by an opt-out physician or practitioner who
has not signed a private contract with a Medicare beneficiary for emergency or urgent
care items and services furnished to, or ordered or prescribed for, such beneficiary on or
after the date the physician opted out.

Where a physician or practitioner who has opted out of Medicare treats a beneficiary with
whom the physician or practitioner does not have a private contract in an emergency or
urgent care situation, the physician or practitioner may not charge the beneficiary more
than the Medicare limiting charge for the service and must submit the claim to Medicare
on behalf of the beneficiary for the emergency or urgent care. Medicare payment may be
made to the beneficiary for the Medicare covered services furnished to the beneficiary.

In other words, where the physician or practitioner provides emergency or urgent care
services to the beneficiary, the physician or practitioner must submit a claim to Medicare,
and may collect no more than the Medicare limiting charge in the case of a physician, or
the deductible and coinsurance in the case of a practitioner. This implements
§1802(b)(2)(A)(iii) of the Act, which specifies that the contract may not be entered into
when the beneficiary is in need of emergency or urgent care. Because the services are
excluded from coverage under §1862(a)(19) of the Act only if they are furnished under
private contract, CMS concludes that they are not excluded in this case where there is no
private contract, notwithstanding that they were furnished by an opt-out physician or