Page 49 - Medicare Benefit Policy Manual

The manual provides in general that Medicare Advantage plans:

• Must acquire and maintain information from Medicare contractors on physicians
and practitioners who have opted out of Medicare.

• Must make no payment directly or indirectly for Medicare covered services
furnished to a Medicare beneficiary by a physician or practitioner who has opted
out of Medicare, except for emergency or urgent care services furnished to a
beneficiary who has not previously entered into a private contract with the
physician or practitioner, in accordance with §40.28.

The Medicare contractor must maintain mutually agreeable means of advising Medicare
Advantage plans of who has opted out. Disputes with Medicare Advantage plans about
the provision of opt out information should be referred to the regional office staff for
resolution.

40.38 - Claims Denial Notices to Opt-Out Physicians and Practitioners
(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)

To ensure that the notice denying payment to the opt-out physician or practitioner
indicates the proper reason for denial of payment, the Medicare contractor must include
language in the notice appropriate to particular circumstances as follows:

• When the claim is submitted inadvertently by the opt-out physician/practitioner,
the Medicare contractor must use claim adjustment reason code 27 (expenses
incurred after coverage terminated) at the claim level with group code PR
(patient responsibility) and the remark code MA47:

Our records show that you have opted out of Medicare, agreeing
with the patient not to bill Medicare for services/tests/supplies
furnished. As a result, we cannot pay this claim. The patient is
responsible for payment.”

• The Medicare contractor uses the following message when the claim is submitted
knowingly and willfully by the opt-out physician/practitioner. It must use claim
adjustment reason code 27 (expenses incurred after coverage terminated) at the
claim level with group code PR (patient responsibility) and the remittance advice
remark code MA47 N771 :

Our records show that you have opted out of Medicare, agreeing
with the patient not to bill Medicare for services/tests/supplies
furnished. As a result, we cannot pay this claim. The patient is
responsible for payment. Alert: Under Federal law you cannot
charge more than the limiting charge amount.

40.39 - Claims Denial Notices to Beneficiaries