decisionhealth Newsletters, Answer Books - 2007 Issue 3 (March)
Medicare_Benefit_Policy_Manual / Chapter_15 / CMS 100-02, 15 40.8
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Article Overview
This chapter section from the Medicare Benefit Policy Manual describes the policy framework for private contracts used in the Medicare opt-out setting. It is aimed at physicians, practitioners, billing staff, and compliance teams that need to understand the required elements of the agreement, timing and recordkeeping expectations, and how these contracts relate to Medicare-covered services, emergency or urgent care, and beneficiary notices.
Why This Topic Matters
The section is important because private contracts affect whether services are handled outside normal Medicare billing pathways and what documentation must be in place to support compliance. It also clarifies the relationship between opt-out arrangements, beneficiary protections, and alternative notice or claim-submission processes.
Article Sections
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Requirements of a Private Contract
Outlines the policy requirements for a private contract in the Medicare opt-out context. The section covers document characteristics, beneficiary acknowledgments, signatures, timing, retention, and availability to CMS.
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Effectiveness of the Private Contract and Opt-Out Affidavit
Describes the affidavit requirement tied to opt-out status and the timing for filing it with Medicare carriers. It also addresses when private contracts must be used after opting out.
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Use of Private Contracts for Covered Services
Explains how private contracts relate to items and services that may be covered by Medicare and notes the exception for emergency or urgent care. It also distinguishes these requirements from services that are clearly excluded from coverage.
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Claim Submission and Advance Beneficiary Notice Context
Summarizes the contrasting responsibilities of non-opt-out physicians, practitioners, and other suppliers when services may be covered by Medicare. It also introduces the use of beneficiary notices in situations where payment may be uncertain.
What You Will Learn
- The purpose and structure of private contracts in the Medicare opt-out setting
- Documentation and timing requirements associated with private contract use
- How private contracts relate to Medicare-covered, excluded, and emergency or urgent care services
- The broader claim-submission and beneficiary-notice context for potentially covered services
Who Should Read This
- Physicians and practitioners
- Medical billing and coding staff
- Practice administrators
- Compliance personnel
- Medicare participation and enrollment specialists
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