Page 48 - Medicare Benefit Policy Manual

• Not have previously opted out of Medicare;

• Notify all Medicare contractors, with which the physician or practitioner filed an
affidavit, of the termination of the opt-out no later than 90 days after the effective
date of the initial 2-year period;

• Refund to each beneficiary with whom the physician or practitioner has privately
contracted all payment collected in excess of:

º The Medicare limiting charge (in the case of physicians or practitioners); or
º The deductible and coinsurance (in the case of practitioners).

• Notify all beneficiaries with whom the physician or practitioner entered into
private contracts of the physician’s or practitioner’s decision to terminate opt-out
and of the beneficiaries’ rights to have claims filed on their behalf with Medicare
for services furnished during the period between the effective date of the opt-out
and the effective date of the termination of the opt-out period.

When the physician or practitioner properly terminates opt-out in accordance with the
second bullet above, the physician or practitioner (who was previously enrolled in
Medicare) will be reinstated in Medicare as if there had been no opt-out, and the
provision of §40.3 must not apply unless the physician or practitioner subsequently
properly opts-out.

40.36 - Appeals
(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)

A determination by CMS that a physician or practitioner has failed to properly opt-out,
failed to maintain opt-out, failed to timely renew opt-out, failed to privately contract,
failed to properly terminate opt-out, or failed to properly cancel opt-out is an initial
determination for purposes of 42 CFR 498.3(b).

A determination by CMS that no payment can be made to a beneficiary for the services of
a physician who has opted out is an initial determination for purposes of 42 CFR
405.924.

See the Medicare Claims Processing Manual, Chapter 29, “Appeals of Claims
Decisions,” for additional information on appeals.

40.37 - Application to the Medicare Advantage Program
(Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)

The Medicare Managed Care Manual contains instructions for Medicare Advantage plans
about the impact on managed care.