Page 47 - Medicare Benefit Policy Manual

recover the payment made for the opt-out physician/practitioner from the
hospital/clinic/group practice, after appropriate notification.

40.31 - Denial of Payment to Beneficiaries and Others
(Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)

If a beneficiary submits a claim that includes items or services furnished by an opt-out
physician or practitioner on dates on or after the effective date of opt out by such
physician or practitioner, the Medicare contractor must deny such items or services
except as permitted by §40.6.

40.32 - Payment for Medically Necessary Services Ordered or
Prescribed by an Opt-out physician or Practitioner
(Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)

If claims are submitted for any items or services ordered or prescribed by an opt out
physician or practitioner under §1802 of the Act, the Medicare contractor may pay for
medically necessary services of the furnishing entity, provided the furnishing entity is not
also a physician or practitioner that has opted out of the Medicare program.

40.33 - Mandatory Claims Submission
(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)

Section 1848(g)(4) of the Act, “Physician/Practitioner Submission of Claims,” regarding
mandatory claims submission, does not apply once a physician or practitioner signs and
submits an affidavit to the Medicare contractor opting out of the Medicare program, for
the duration of the physician’s or practitioner’s opt-out period, unless the physician or
practitioner knowingly and willfully violates a term of the affidavit.

40.34 - Cancellation of Opt-Out
(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)

A physician or practitioner may cancel opt-out by submitting a written notice to each
MAC to which he or she would file claims absent the opt-out, not later than 30 days
before the end of the current 2-year opt-out period, indicating that the physician or
practitioner does not want to extend the application of the opt-out affidavit for a
subsequent 2-year period.

40.35 - Early Termination of Opt-Out
(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)

If a physician or practitioner changes his or her mind after the Medicare contractor has
approved the affidavit, the opt-out may be terminated within 90 days of the effective date
of the affidavit. To properly terminate an opt-out, a physician or practitioner must: