Page 50 - Medicare Benefit Policy Manual

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

To ensure that the notice to the beneficiary indicates the proper reason for denial of
payment, the Medicare contractor must include language in the notice appropriate to
particular circumstances as follows:

• It must use the following MSN message when the claim is submitted
inadvertently by the opt-out physician/practitioner:

MSN # 21.20 - “The provider decided to drop out of Medicare. No
payment can be made for this service. You are responsible for this
charge.”

• It must use the following message when the claim is submitted knowingly and
willfully by the opt-out physician/practitioner:

MSN # 21.19 - “The provider decided to drop out of Medicare. No
payment can be made for this service. You are responsible for this
charge. Under Federal law your doctor cannot charge you more
than the limiting charge amount.”

• It must use the following message when the claim is submitted by the beneficiary
for a service furnished by an opt-out physician/practitioner:

MSN # 21.20 - “The provider decided to drop out of Medicare. No
payment can be made for this service. You are responsible for this
charge.”

50 - Drugs and Biologicals
(Rev. 1, 10-01-03)
B3-2049, A3-3112.4.B, HO-230.4.B

The Medicare program provides limited benefits for outpatient drugs. The program
covers drugs that are furnished “incident to” a physician’s service provided that the drugs
are not usually self-administered by the patients who take them.

Generally, drugs and biologicals are covered only if all of the following requirements are
met:

• They meet the definition of drugs or biologicals (see §50.1);

• They are of the type that are not usually self-administered. (see §50.2);

• They meet all the general requirements for coverage of items as incident to a
physician’s services (see §§50.1 and 50.3);