decisionhealth Newsletters, Answer Books - 2007 Issue 3 (March)
Medicare_Benefit_Policy_Manual / Chapter_15 / CMS 100-02, 15 40.5
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Article Overview
This Medicare Benefit Policy Manual section addresses how Medicare treats services furnished by physicians or practitioners who have opted out of Medicare. It is relevant to providers, billing staff, compliance teams, and hospital reimbursement personnel who need to understand the scope of nonpayment, exceptions for urgent care situations, and the general framework for covered services tied to an opting-out practitioner. The article presents policy guidance and operational conditions without going into coding methodology.
Why This Topic Matters
Understanding opt-out policy helps avoid inappropriate billing and payment errors when a practitioner has formally opted out of Medicare. It also clarifies when Medicare may still pay for certain covered services connected to that practitioner and how emergency situations are handled.
What You Will Learn
- How Medicare treats services furnished by practitioners who have opted out
- What general payment restrictions apply in opt-out situations
- How emergency or urgent care situations are addressed
- How Medicare considers covered services ordered by an opting-out practitioner
- What types of stakeholders are affected by opt-out policy
Who Should Read This
- Physicians
- Practitioners
- Medical coders
- Billing staff
- Hospital reimbursement teams
- Compliance professionals
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