evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
40.16 - Relationship Between Opt -Out and Medicare Participation Agreements  (Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)  Participation agreements will terminate on the opt out effective date. See 40.17 for effective date provisions.  Physicians and practitioners may not provide services under private contracts with beneficiaries earlier than the effective date of the affidavit.  Nonparticipating physicians and practitioners may opt out at any time.  The Medicare contractor must update the system files so that it may timely pay participating physicians and practitioners at the correct payment amounts in effect for that part of the fee schedule year before they opt out and to pay them as nonparticipating for emergency or urgent care as of their opt out effective date.   40.17 - Participating Physicians and Practitioners  (Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)  Participating physicians and practitioners may opt out if they file an affidavit that meets the criteria and which is received by the Medicare contractor at least 30 days before the first day of the next calendar quarter showing an effective date of the first day in that quarter (i.e., January 1, April 1, July 1, October 1).  They may not provide services under private contracts with beneficiaries earlier than the effective date of the affidavit.   The 30-day notice is required to allow sufficient time for the Medicare contractor to accomplish the appropriate system file updates before the effective date.  The Medicare contractor must make participating physician status changes no less frequently than at the beginning of each calendar quarter.  Therefore, participating physicians or practitioners must provide the Medicare contractor with 30 days notice that they intend to opt out at the beginning of the next calendar quarter.  Participating physicians or practitioners may sign private contracts only after the effective date of affidavits filed in accordance with 40.9.  They may not provide services under private contracts with beneficiaries earlier than the effective date of the affidavit.  It is necessary to treat nonparticipating physicians or practitioners differently from participating physicians or practitioners in order to assure that participating physicians or practitioners are paid properly for the services they furnish before the effective date of the affidavit.
(Medicare Benefit Policy Manual)
Participating physicians or practitioners are paid at the full fee schedule for the services they furnish to Medicare beneficiaries.  However, the law sets the payment amount for nonparticipating physicians or practitioners at 95 percent of the payment amount for participating physicians or practitioners.  Participating physicians or practitioners who opt out are treated as nonparticipating physicians or practitioners as of the effective date of the opt -out affidavit.  When a participating physician/practitioner opts out of Medicare, the Medicare contractor must pay the physician/practitioner at the higher participating physician/practitioner rate for services rendered in the period before the effective date of the opt -out; and at the nonparticipating rate for services rendered on and after the opt-out date.
(Medicare Benefit Policy Manual)
40.18 - Physicians or Practitioners Who Choose to Opt Out of Medicare  (Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)  If a physician/practitioner chooses to opt-out of Medicare, it means that the physician/ practitioner opts-out for all covered items and services that he or she furnishes.  Physicians and practitioners cannot have private contracts that apply to some covered services they furnish but not to others.  For example, if a physician or practitioner provides laboratory tests or durable medical equipment incident to his or her professional services and chooses to opt-out of Medicare, then the physician/practitioner has opted out of Medicare for payment of lab services and Durable Medical Equipment, Prosthetics, and Orthotics (DMEPOS) as well as for professional services.  If a physician or practitioner has a valid opt-out affidavit on file with the MAC, has a valid NPI, is a specialty that is eligible to order or certify, and refers a beneficiary to a non-opt-out physician or practitioner for medically necessary services, such as laboratory, DMEPOS or inpatient hospitalization, Medicare would cover those services.  In addition, because suppliers of DMEPOS, independent diagnostic testing facilities, clinical laboratories, etc., cannot opt-out, the physician or practitioner owner of such suppliers cannot opt-out as such a supplier.  Therefore, the participating physician or practitioner becomes a nonparticipating physician or practitioner for purposes of Medicare payment for emergency and urgent care services on the effective date of the opt-out.  (See 40.28).  40.19 - Opt-Out Relationship to Noncovered Services (Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08 -15-16)
(Medicare Benefit Policy Manual)
40.19 - Opt-Out Relationship to Noncovered Services (Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08 -15-16)  Because Medicares rules do not apply to items or services that are categorically not covered by Medicare, a private contract is not needed to furnish such items or services to Medicare beneficiaries, and Medicares claims filing rules and limits on charge s do not apply to such items or services.  For example, because Medicare does not cover hearing aids, a physician or practitioner, or other supplier may furnish a hearing aid to a Medicare beneficiary and would not be required to file a claim with Medicare; further, the physician, practitioner, or other supplier would not be subject to any Medicare limit on the amount they could collect for the hearing aid.  If the item or service is one that is not categorically excluded from coverage by Medicare, but may be noncovered in a given case (for example, it is covered only where certain clinical criteria are met and there is a question as to whether the criteria ar e met), a non -opt-out physician/practitioner or other supplier is not  relieved of his or her obligation to file a claim with Medicare.  If the physician or practitioner or other supplier has given a proper Advance Beneficiary Notice (ABN), he or she may collect from the beneficiary the full charge if Medicare does deny the claim.   Where a physician or practitioner has opted out of Medicare, he or she must provide covered services only through private contracts that meet the criteria specified in 40.8 (including items and services that are not categorically excluded from coverage but may be excluded in a given case).  An opt-out physician or practitioner is prohibited from submitting claims to Medicare (except for emergency or urgent care services furnished to a beneficiary with whom the physician or practitioner did not have a private contract).  (See 40.12 .)
(Medicare Benefit Policy Manual)
40.20 - Maintaining Information on Opt -Out Physicians  (Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)  The Medicare contractor must maintain information on the opt-out physicians or practitioners.  At a minimum, it must capture the name and TIN of the physician or practitioner, the effective date of the opt-out affidavit, and the automatic 2- year renewal date for affidavits filed on or after June 16, 2015.  If the physician/practitioner cancels opt- out (see 40.34), then the Medicare contractor must also maintain the physician/practitioners opt -out end date or cancellation date.  The Medicare contractor may also include other provider -specific information it may need.  If cost effective, it may house this information on its provider file.   40.21 - Informing Medicare Managed Care Plans of the Identity of the Opt -Out Physicians or Practitioners (Rev. 222, Issued: 05- 13-16, Effective: 08 -15-16, Implementation; 08- 15-16)  The Medicare contractor must develop data exchange mechanisms for furnishing Medicare managed care plans in its service area with timely information on physicians and practitioners who have opted out of Medicare.  For example, it may wish to establish an I nternet website Home Page which houses all of the information on physicians or practitioners who have opted out.  It will need to negotiate appropriate opt -out information exchange mechanisms with each managed care plan in its service area.   40.22 - Informing the National Supplier Clearinghouse (NSC) of the Identity of the Opt-Out Physicians or Practitioners  (Rev. 160, Issued: 10- 26-12, Effective: 01 -28-13, Implementation: 01- 28-13)  The Medicare contractor must notify the NSC directly with timely information on physicians or practitioners who have opted out of Medicare.  An Internet Web site Home Page is not an acceptable means of notifying the NSC.  The NSCs address is as follows:   National Supplier Clearinghouse  P.O. Box 100142 Columbia, SC 29202- 3142  40.23 - Organizations That Furnish Physician or Practitioner Services  (Rev. 1, 10- 01-03) B3-3044.23
(Medicare Benefit Policy Manual)
40.23 - Organizations That Furnish Physician or Practitioner Services  (Rev. 1, 10- 01-03) B3-3044.23  The opt -out applies to all items or services the physician or practitioner furnishes to Medicare beneficiaries, regardless of the location where such items or services are furnished.   Where a physician or practitioner opts out and is a member of a group practice or otherwise reassigns his or her rights to Medicare payment to an organization, the organization may no longer bill Medicare or be paid by Medicare for services that the physic ian or practitioner furnishes to Medicare beneficiaries.  However, if the physician or practitioner continues to grant the organization the right to bill and be paid for the services the physician or practitioner furnishes to patients, the organization may bill and be paid by the beneficiary for the services that are provided under the private contract.  The decision of a physician or practitioner to opt out of Medicare does not affect the ability of the group practice or organization to bill Medicare for t he services of physicians and practitioners who have not opted out of Medicare.  Corporations, partnerships, or other organizations that bill and are paid by Medicare for the services of physicians or practitioners who are employees, partners, or have other arrangements that meet the Medicare reassignment -of-payment rules cannot opt out because they are neither physicians nor practitioners.  Of course, if every physician and practitioner within a corporation, partnership, or other organization opts out, then such corporation, partnership, or other organization would have, in effect, opt ed out.   40.24 - The Difference Between Advance Beneficiary Notices (ABN) and Private Contracts  (Rev. 1, 10- 01-03) B3-3044.24  An Advance Beneficiary Notice (ABN) allows a beneficiary to make an informed consumer decision by knowing in advance that the beneficiary may have to pay out-of-pocket.  An ABN is not needed where the item or service is categorically excluded from Medicare coverage or outside the scope of the benefit.   An ABN is used when the physician/practitioner believes that Medicare will not make payment, while private contracts are used for services that are covered by Medicare and for which payment might be made if a claim were to be submitted.
(Medicare Benefit Policy Manual)
An ABN is used when the physician/practitioner believes that Medicare will not make payment, while private contracts are used for services that are covered by Medicare and for which payment might be made if a claim were to be submitted.   See the Medicare Claims Processing Manual, chapter 30, for a description of the ABN.  40.25 - Private Contracting Rules When Medicare is the Secondary Payer  (Rev. 1, 10-01-03) B3-3044.25  The opt- out physician/practitioner must have a private contract with a Medicare beneficiary for all Medicare- covered services (see 40.7), notwithstanding that Medicare would be the secondary payer in a given situation.  No Medicare primary or  secondary payments will be made for items and services furnished by a physician/practitioner under the private contract.
(Medicare Benefit Policy Manual)
40.26 - Registration and Identification of Physicians or Practitioners Who Opt Out (Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)  If the Medicare contractor has the physicians/practitioners NPI, then the Medicare contractor should use it in order to identify opt-out physicians or practitioners nationwide.  However, if the physician/practitioner does not have an NPI, then the Medicare contractor must use the physicians or practitioners TIN to identify opt-out physicians or practitioners nationwide.  40.27 - System Identification  (Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)  The Medicare contractor must ensure that its system can automatically identify claims that include services furnished by providers or practitioners who have opted out of Medicare.  It must not make payment to any opt-out physician/practitioner for items or services furnished on or after the effective date of the physicians or practitioners opt out affidavit unless there are emergency or urgent care situations involved.  In an emergency or urgent care situation, payment can be made for services furnished t o a Medicare beneficiary if the beneficiary has no contract with the opt-out physician/practitioner.  See the following section for related instructions.  40.28 - Emergency and Urgent Care Situations (Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)  Payment may be made for services furnished by an opt-out physician or practitioner who has not signed a private contract with a Medicare beneficiary for emergency or urgent care items and services furnished to, or ordered or prescribed for, such beneficiary on or after the date the physician opted out.  Where a physician or practitioner who has opted out of Medicare treats a beneficiary with whom the physician or practitioner does not have a private contract in an emergency or urgent care situation, the physician or practitioner may not charge the benefic iary more than the Medicare limiting charge for the service and must submit the claim to Medicare on behalf of the beneficiary for the emergency or urgent care.  Medicare payment may be made to the beneficiary for the Medicare covered services furnished to  the beneficiary.
(Medicare Benefit Policy Manual)
In other words, where the physician or practitioner provides emergency or urgent care services to the beneficiary, the physician or practitioner must submit a claim to Medicare, and may collect no more than the Medicare limiting charge in the case of a phy sician, or the deductible and coinsurance in the case of a practitioner.  This implements 1802(b)(2)(A)(iii)  of the Act, which specifies that the contract may not be entered into when the beneficiary is in need of emergency or urgent care.  Because the services are excluded from coverage under 1862(a)(19)  of the Act only if they are furnished under private contract, CMS concludes that they are not excluded in this case where there is no private contract, notwithstanding that they were furnished by an opt-out physician or practitioner.  Hence, they are covered services furnished by a nonparticipating physician or practitioner, and the rules in effect absent the opt-out would apply in these cases.  Specifically, the physician or practitioner may choose to take assignment (thereby agreeing to collect no more than the Medicare deductible and coinsurance based on the allowed amount from the beneficiary) or not to take assignment (and to collect no more than the Medicare limiting charge), but the practitioner must take assignment under 1842(b)(18)  of the Act.   Therefore, in this circumstance the physician or practitioner must submit a completed Medicare claim on behalf of the beneficiary with the appropriate HCPCS code and HCPCS modifier that indicates the services furnished to the Medicare beneficiary were emergency or urgent care services and the beneficiary does not have a private contract with the physician or practitioner.  If the physician or practitioner did not submit the GJ national HCPCS modifier, then the Medicare contractor must deny the claim so that the beneficiary can appeal.   GJ = Opt -out physician/practitioner EMERGENCY OR URGENT SERVICES
(Medicare Benefit Policy Manual)
This modifier must be used on claims for services rendered by an opt-out physician/ practitioner for an emergency/urgent care service.  The use of this modifier indicates that the service was furnished by an opt-out physician/practitioner who has not signed a private contract with a Medicare beneficiary for emergency or urgent care items and services furnished to, or ordered or prescribed for, such beneficiary on or after the date the physician/practitioner opted out.  The Medicare contractor must deny payment for emergency or urgent care items and services to both an opt-out physician or practitioner and the beneficiary if these parties have previously entered into a private contract, i.e., prior to the furnishing of the emergency or urgent care items or services but within the physicians or practitioners current 2-year  period.  Under the emergency and urgent care situation where an opt-out physician or practitioner renders emergency or urgent service to a Medicare beneficiary (e.g., a fractured leg) who has not entered into a private agreement with the physician or practitioner, as stated above the physician or practitioner is required to submit a claim to Medicare with the appropriate modifier (GJ and 54 as discussed further below) and is subject to all the rules and regulations of Medicare, including the limiting charge.  However, if the opt-out physician or practitioner asks the beneficiary, with whom the physician or practitioner has no private contract, to return for a follow up visit (e.g., return within 5 to 6 weeks to remove the cast and examine the leg) the physician or practitioner must ask the beneficiary to sign a private contract.  In other words, once a beneficiary no longer needs emergency or urgent care (i.e., non-urgent follow up care), Medicare cannot pay for the follow up care and the physician or practitioner can and must, under the opt-out affidavit agreement, ask the beneficiary to sign a private contract as a condition of further treatment.  The way this would work in the fractured leg example (see previous paragraph) is that the physician or practitioner would bill Medicare for the setting of the fractured leg with the emergency opt-out HCPCS modifier  (GJ) and the surgical care only modifier (54) to ensure that Medicare does not pay the Evaluation and Management (E&M) that is in the global fee for the
(Medicare Benefit Policy Manual)
leg with the emergency opt-out HCPCS modifier  (GJ) and the surgical care only modifier (54) to ensure that Medicare does not pay the Evaluation and Management (E&M) that is in the global fee for the procedure.  The physician or practitioner would then either have the beneficiary sign the private contract or refer the beneficiary to a Medicar e physician or practitioner who would bill Medicare using the post op only modifier to be paid for the post op care in the global period.  If the beneficiary continues to be in a condition that requires emergency or urgent care (i.e., unconscious or unstable after surgery for an aneurysm) follow up care would continue to be paid under emergency or urgent care until such time as the beneficiar y no longer needed such care.  In the absence of incontrovertible evidence, CMS recommends accepting what the physician or practitioner says via the modifiers and doing post-pay records review of frequent users of the opt-out modifier.  40.29 - Definition of Emergency and Urgent Care Situations  (Rev. 206, Issued: 04-10-15, Effective: 07-13-15, Implementation: 07-13-15)  Emergency care services means inpatient or outpatient hospital services that are necessary to prevent death or serious impairment of health and, because of the danger to life or health, require use of the most accessible hospital available and equipped to furnish those services.  Congress intended that the term emergency or urgent care services not be limited to emergency services since they also included urgent care services.  Urgent Care Services are defined in 42 CFR 405.400
(Medicare Benefit Policy Manual)
as services furnished within 12 hours in order to avoid the likely onset of an emergency medical condition.  For example, if a beneficiary has an ear infection with significant pain, CMS would view that as requiring treatment to avoid the adverse consequences of continued pain and perforation of the eardrum.  The patients condition would not meet the definition of emergency medical condition because immediate care is not needed to avoid placing the health of the individual in serious jeopardy or to avoid serious impairment or dysfunction.  However, although it does not meet the definition of emergency care, the beneficiary needs care within a relatively short period of time (which CMS defines as 12 hours) to avoid adverse consequences, and the beneficiary may not be able to find another physician or practitioner to provide treatment within 12 hours.  40.30 - Denial of Payment to Employers of Opt -Out Physicians and Practitioners  (Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)  If an opt-out physician or practitioner is employed in a hospital setting and submits bills for which payment is prohibited, the Medicare contractor usually detects and investigates the situation.  However, in some instances an opt-out physician or practit ioner may have a salary arrangement with a hospital or clinic or work in a group practice and may not directly submit bills for payment.  If the Medicare contractor detects this situation, it must recover the payment made for the opt-out physician/practitioner from the hospital/clinic/group practice, after appropriate notification.   40.31 - Denial of Payment to Beneficiaries and Others  (Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)  If a beneficiary submits a claim that includes items or services furnished by an opt-out physician or practitioner on dates on or after the effective date of opt out by such physician or practitioner, the Medicare contractor must deny such items or service s except as permitted by 40.6.  40.32 - Payment for Medically Necessary Services Ordered or Prescribed by an Opt -out physician or Practitioner  (Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)  If claims are submitted for any items or services ordered or prescribed by an opt out physician or practitioner under 1802