As provided in §4507 of the Balanced Budget Act of 1997, a "private contract" is a contract between a Medicare beneficiary and an eligible practitioner who has "opted out" of Medicare for two years for all covered items and services he or she furnishes to Medicare beneficiaries.
In a private contract, the Medicare beneficiary agrees to give up Medicare payment for services furnished by the eligible practitioner and to pay the eligible practitioner without regard to any limits that would otherwise apply to what the eligible practitioner could charge.
An eligible practitioner who wants to opt out must provide all basic information so that he/she can be appropriately identified in opt-out files. An example of an affidavit is provided for consideration.
A. Effect of beneficiary agreements not to use Medicare coverage
B. General rules of private contracts
C. Definition of an eligible practitioner
D. When an eligible practitioner opt out of Medicare
E. Definition of a private contract
F. Requirements of a private contract
G. Requirements of the opt-out affidavit
H. Failure to properly opt-out
I. Failure to maintain opt-out
J. Opt-out effective dates
K. Non-covered services
L. Organizations that furnish eligible practitioner services
M. Emergency and urgent care situations
N. Renewal of opt-out
O. Early termination of opt-out
P. Cancellation of opt-out
Q. Out-out renewal alert letter
R. Appeal process for opt-out decisions
A. Effect of beneficiary agreements not to use Medicare coverage
Normally eligible practitioners are required to submit claims on behalf of beneficiaries for all items and services they provide for which Medicare payment may be made under Part B. Also, they are not allowed to charge beneficiaries in excess of the limits on charges that apply to the item or service being furnished.
However, an eligible practitioner may opt-out of Medicare. An eligible practitioner who opts out is not required to submit claims on behalf of beneficiaries and also is excluded from limits on charges for Medicare covered services.
An eligible practitioner who has opted out of Medicare is not subject to reporting requirements of Medicare enrolled physician/non-physician practitioners.
B. General rules of private contracts
The following rules apply to eligible practitioners who opt-out of Medicare:
An eligible practitioner may enter into one or more private contracts with Medicare beneficiaries for the purpose of furnishing items or services that would otherwise be covered by Medicare.
An eligible practitioner who enters into at least one private contract with a Medicare beneficiary and who submits one or more affidavits opts out of Medicare for a 2-year period, unless the opt-out is terminated early or unless the eligible practitioner fails to maintain opt-out. The eligible practitioner's opt-out may be renewed for subsequent 2-year periods.
Effective with affidavits signed on or after June 16, 2015, eligible practitioners will no longer be required to file renewal affidavits. If the eligible practitioner does not want to extend their opt-out status at the end of the two year opt period, they may cancel by notifying all Medicare contractors with which they filed an affidavit in writing at least 30 days prior to the start of the next two year opt-out period.
Both the private contracts and the eligible practitioner's opt-out are null and void if the eligible practitioner fails to properly opt-out in accordance with the opt-out conditions.
Both the private contracts and the eligible practitioner's opt-out are null and void for the remainder of the opt-out period if the eligible practitioner fails to remain in compliance with the opt-out conditions during the opt-out period.
Services furnished under private contracts meeting the opt-out requirements/conditions are not covered services under Medicare, and no Medicare payment will be made for such services either directly or indirectly to the eligible practitioner nor will Medicare issue payment to the beneficiary.
C. Definition of an eligible practitioner
For purposes of the opt-out provision, the term "physician" is limited to doctors of medicine; doctors of osteopathy; doctors of dental surgery or of dental medicine; doctors of podiatric medicine; and doctors of optometry who are legally authorized to practice dentistry, podiatry, optometry, medicine, or surgery by the State in which such function or action is performed; no other physicians may opt-out. Also, for purposes of this provision, the term "practitioner" means any of the following to the extent that they are legally authorized to practice by the State and otherwise meet Medicare requirements:
Physician assistant;
Nurse practitioner;
Clinical nurse specialist;
Certified registered nurse anesthetist;
Certified nurse midwife;
Clinical psychologist;
Registered dietitian; or nutrition professional;
Marriage and family therapist;
Mental health counselor.
The opt-out law does not define "physician" to include chiropractors; therefore, they may not opt out of Medicare and provide services under private contract. Physical therapists in independent practice and occupational therapists in independent practice cannot opt out because they are not within the opt-out law's definition of either a "physician" or "practitioner".
Suppliers of service (durable medical equipment, prosthetics, orthotics, and supplies, independent diagnostic testing facilities, clinical laboratories, ambulance suppliers, etc.) cannot opt-out nor can a physician or practitioner owner of such suppliers.
D. When an eligible practitioner opts out of Medicare
When an eligible practitioner opts out of Medicare, Medicare covers no services provided by that individual and no Medicare payment can be made to that eligible practitioner directly or on a capitated basis. Additionally, no Medicare payment may be made to a beneficiary for items or services provided directly by an eligible practitioner who has opted out of the program.
Exception: In an emergency or urgent care situation, an eligible practitioner who opts out may treat a Medicare beneficiary with whom he/she does not have a private contract and bill for such treatment. In such a situation, the eligible practitioner may not charge the beneficiary more than the Medicare limiting charge for the service and must submit a claim to Medicare on the beneficiary's behalf. Payment will be made for Medicare covered items or services furnished in emergency or urgent situations when the beneficiary has not signed a private contract with that eligible practitioner.
Under the statute, the eligible practitioner cannot choose to opt-out of Medicare for some Medicare beneficiaries but not others; or for some services but not others. The eligible practitioner who chooses to opt-out of Medicare may provide covered care to Medicare beneficiaries only through private agreements.
Medicare will make payment for covered, medically necessary services that are ordered by an eligible practitioner who has opted out of Medicare if the ordering eligible practitioner has acquired a NPI and provided that the services are not furnished by another eligible practitioner who has also opted out. For example, if an opt-out eligible practitioner admits a beneficiary to a hospital, Medicare will reimburse the hospital for medically necessary care.
E. Definition of a private contract
A "private contract" is a contract between a Medicare beneficiary and an eligible practitioner who has opted out of Medicare for two years for all covered items and services the eligible practitioner furnishes to Medicare beneficiaries. In a private contract, the Medicare beneficiary agrees to give up Medicare payment for services furnished by the eligible practitioner and to pay the eligible practitioner without regard to any limits that would otherwise apply to what the eligible practitioner could charge.
Pursuant to the statute, once an eligible practitioner files an affidavit notifying the Medicare contractor that the he/she has opted out of Medicare, the eligible practitioner is out of Medicare for two years from the date the affidavit is signed (unless the opt-out is terminated early) or unless the eligible practitioner fails to maintain opt-out. After those two years are over, an eligible practitioner could elect to return to Medicare or to opt-out again.
A beneficiary who signs a private contract with an eligible practitioner is not precluded from receiving services from other physicians and practitioners who have not opted out of Medicare.
Eligible practitioners who provide services to Medicare beneficiaries enrolled in the new medical savings account demonstration created by the Balanced Budget Act of 1997 are not required to enter into a private contract with those beneficiaries and to opt out of Medicare under §1802 of the Act.
The opt-out eligible practitioner must have a private contract with a Medicare beneficiary for all Medicare-covered services, 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 an eligible practitioner under the private contract.
F. Requirements of a private contract
A private contract must:
Be in writing and in print sufficiently large to ensure that the beneficiary is able to read the contract;
Clearly state whether the eligible practitioner is excluded from Medicare under §§1128, 1156 or 1892 of the Social Security Act;
State that the beneficiary or his/her legal representative accepts full responsibility for payment of the eligible practitioner's charge for all services furnished by the eligible practitioner;
State that the beneficiary or his/her legal representative understands that Medicare limits do not apply to what the eligible practitioner may charge for items or services furnished by the eligible practitioner;
State that the beneficiary or his/her legal representative agrees not to submit a claim to Medicare or to ask the eligible practitioner to submit a claim to Medicare;
State that the beneficiary or his/her legal representative understands that Medicare payment will not be made for any items or services furnished by the eligible practitioner that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted;
State that the beneficiary or his/her legal representative enters into the contract with the knowledge that he/she has the right to obtain Medicare-covered items and services from eligible practitioners who have not opted out of Medicare, and that the beneficiary is not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted out;
State the expected or known effective date and expected or known expiration date of the opt-out period;
State that the beneficiary or his/her legal representative understands that Medigap plans do not, and that other supplemental plans may elect not to, make payment for items and services not paid for by Medicare;
Be signed by the beneficiary or his/her legal representative and by the eligible practitioner;
Not be entered into by the beneficiary or by the beneficiary's legal representative during a time when the beneficiary requires emergency care services or urgent care services;
Be provided (a photocopy is permissible) to the beneficiary or to his/her legal representative before items or services are furnished to the beneficiary under the term of the contract;
Be retained (original signatures of both parties required) by the eligible practitioner for the duration of the opt-out period;
Be made available to CMS upon request; and
Be entered into for each opt-out period.
In order for a private contract with a beneficiary to be effective, the eligible practitioner must file an affidavit with all Medicare contractors to which he/she would submit claims, advising that he/she has opted out of Medicare. The affidavit must be filed within 10 days of entering into the first private contract with a Medicare beneficiary.
Once the eligible practitioner has opted out, such eligible practitioner must enter into a private contact with each Medicare beneficiary to whom he/she furnished covered services (even where Medicare payment would be on a capitated basis or where Medicare would pay an organization for the physician's or practitioner's services to the Medicare beneficiary), with the exception of a Medicare beneficiary needing emergency or urgent care.
If an eligible practitioner has opted out of Medicare, the eligible practitioner must use a private contract for items and services that are, or may be, covered by Medicare (except for emergency or urgent care services). An opt-out eligible practitioner is not required to use a private contract for an item or service that is excluded from coverage by Medicare.
You may send the complete contract by mail or fax to:
Novitas Solutions
PO box 3157
Mechanicsburg, PA 17055-1836
Fax: 877-439-5479
G. Requirements of the opt-out affidavit
To be valid, the affidavit must:
Be in writing and be signed by the eligible practitioner;
Contain the eligible practitioner's full name, birthdate, address, telephone number, NPI, or, if an NPI has not been assigned, the eligible practitioner's social security number;
State that, except for emergency or urgent care services (as specified in §40.28), during the opt-out period the eligible practitioner will provide services to Medicare beneficiaries only through private contracts that meet the criteria of §40.8 for services that, but for their provision under a private contract, would have been Medicare-covered services;
State that the eligible practitioner will not submit a claim to Medicare for any service furnished to a Medicare beneficiary during the opt-out period, nor will the eligible practitioner permit any entity acting on the eligible practitioner's behalf to submit a claim to Medicare for services furnished to a Medicare beneficiary, except as specified in §40.28;
State that, during the opt-out period, the eligible practitioner understands that the eligible practitioner may receive no direct or indirect Medicare payment for services that the eligible practitioner furnishes to Medicare beneficiaries with whom the eligible practitioner has privately contracted, whether as an individual, an employee of an organization, a partner in a partnership, under a reassignment of benefits, or as payment for a service furnished to a Medicare beneficiary under a Medicare advantage plan;
State that an eligible practitioner who opts out of Medicare acknowledges that, during the opt-out period, the eligible practitioner's services are not covered under Medicare and that no Medicare payment may be made to any entity for the eligible practitioners services, directly or on a capitated basis;
State on acknowledgment by the eligible practitioner to the effect that, during the opt-out period, the eligible practitioner agrees to be bound by the terms of both the affidavit and the private contracts that the eligible practitioner has entered into;
Acknowledge that the eligible practitioner recognizes that the terms of the affidavit apply to all Medicare-covered items and services furnished to Medicare beneficiaries by the eligible practitioner during the opt-out period (except for emergency or urgent care services furnished to the beneficiaries with whom the eligible practitioner has not previously privately contracted) without regard to any payment arrangements the eligible practitioner may make;
With respect to a eligible practitioner who has signed a Part B participation agreement, acknowledge that such agreement terminates on the effective date of the affidavit;
Acknowledge that the eligible practitioner understands that a beneficiary who has not entered into a private contract and who requires emergency or urgent care services may not be asked to enter into a private contract with respect to receiving such services and that the rules of §40.28 apply if the eligible practitioner furnishes such services;
Identify the eligible practitioner sufficiently so that the contractor can ensure that no payment is made to the eligible practitioner during the opt-out period;
Be filed with all contractors who have jurisdiction over claims the eligible practitioner would otherwise file with Medicare and be filed no later than 10 days after the first private contract to which the affidavit applies is entered into; and
An example of an
affidavit is provided for consideration. The terms of the affidavit should be carefully reviewed for compliance by all eligible practitioners who are considering opting out of Medicare. An eligible practitioner who is enrolled in Medicare must provide all basic information so that he/she can be appropriately identified in opt-out files.
H. Failure to properly opt out
An eligible practitioner fails to properly opt-out for any of the following reasons:
Any private contract between the eligible practitioner and a Medicare beneficiary that was entered into before the affidavit was filed does not meet the requirements; or
The eligible practitioner fails to properly submit the affidavit(s).
If an eligible practitioner fails to properly opt out in accordance with the above paragraphs of this section, the following will result:
The eligible practitioner's attempt to opt-out of Medicare is nullified, and all of the private contracts between the eligible practitioner and Medicare beneficiaries for the two-year period covered by the attempted opt-out are deemed null and void;
The eligible practitioner must submit claims to Medicare for all Medicare-covered items and services furnished to Medicare beneficiaries, including the items and services furnished under the nullified contracts. A nonparticipating eligible practitioner is subject to the limiting charge provision. For items or services paid under the physician fee schedule, the limiting charge is 115 percent of the approved amount for nonparticipating eligible practitioners. A participating eligible practitioner is subject to the limitations on charges of the participation agreement the eligible practitioner signed;
The eligible practitioner may neither bill nor collect an amount from the beneficiary except for applicable deductible and coinsurance amounts; and
The eligible practitioner may make another attempt to properly opt out at any time.
I. Failure to maintain opt-out
An eligible practitioner fails to maintain opt-out under this section if during the opt-out period one of the following occurs:
The eligible practitioner has filed an affidavit and has signed private contracts but, the eligible practitioner knowingly and willfully submits a claim for Medicare payment (except for emergency or urgent care) or the eligible practitioner receives Medicare payment directly or indirectly for Medicare-covered services furnished to a Medicare beneficiary (except for emergency or urgent care); or
The eligible practitioner fails to enter into private contracts with Medicare beneficiaries for the purpose of furnishing items and services that would otherwise be covered by Medicare, or enters into private contracts that fail to meet the required specifications; or
The eligible practitioner fails to comply with the provisions of emergency or urgent care services regarding billing for those services; or
The eligible practitioner fails to retain a copy of each private contract that the eligible practitioner has entered into for the duration of the opt-out period for which the contracts are applicable or fails to permit CMS to inspect them upon request.
Violation discovered by the contractor during the opt-out period.
If an eligible practitioner fails to maintain opt-out in accordance with the opt-out provisions, and fails to demonstrate within 45 days of a notice from the contractor that the eligible practitioner has taken good faith efforts to maintain opt-out (including by refunding amounts in excess of the charge limits to the beneficiaries with whom the eligible practitioner did not sign a private contract), the following will result effective 46 days after the date of the notice, but only for the remainder of the opt-out period:
All the private contracts between the eligible practitioner and Medicare beneficiaries are deemed null and void.
The eligible practitioner's opt-out of Medicare is nullified.
The eligible practitioner must submit claims to Medicare for all Medicare covered items and services furnished to Medicare beneficiaries.
The eligible practitioner or beneficiary will not receive Medicare payment on Medicare claims for the remainder of the opt-out period, except as stated above.
The eligible practitioner is subject to the limiting charge provisions.
The eligible practitioner may neither bill nor collect any amount from the beneficiary except for applicable deductible and coinsurance amounts.
The eligible practitioner may not attempt to once more meet the criteria for properly opting out until the 2-year opt-out period expires.
Violation not discovered by the contractor during the 2-year opt-out period.
In situations where a violation of failure to maintain opt out is not discovered by the contractor during the opt-out period when the violation actually occurred, the requirements listed in the preceding section, violations discovered by the contractor during the opt-out period, are applicable from the date that the first violation of failure to maintain opt-out occurred until the end of the opt-out period during which the violation occurred (unless the eligible practitioner takes good faith efforts, within 45 days of any notice from the contractor that the eligible practitioner failed to maintain opt-out, or within 45 days of the eligible practitioner's discovery of the failure to maintain opt-out, whichever is earlier, to correct his or her violations of failure to maintain opt-out. Good faith efforts include, but are not necessarily limited to, refunding any amounts collected in excess of the charge limits from beneficiaries with whom he or she did not sign a private contract).
J. Opt-out effective dates
Eligible practitioners receive effective date based on their participation status:
Eligible practitioners that have never enrolled with Medicare:
If a non-enrolled eligible practitioner submits an opt-out affidavit, the effective date of the opt-out period begins the date the affidavit is signed by the eligible practitioner.
Previously enrolled non-participating practitioners:
If a previously enrolled non-participating practitioner decides to terminate his/her active billing enrollment and opt-out of Medicare, the effective date of the opt-out period begins the date the affidavit is signed by the eligible practitioner.
Previously enrolled participating physicians/suppliers:
If a previously enrolled participating practitioner decides to terminate his/her active billing enrollment and opt-out of Medicare, the effective date of the opt-out period begins the first date of the next calendar quarter.
An opt-out affidavit must be received at least 30 days before the first day of the calendar quarter in order to receive January 1, April 1, July 1 or October 1 as the effective date. If the opt-out affidavit is received within 30 days prior to January 1, April 1, July 1 or October 1, the effective date would be the first day of the next calendar quarter.
K. Non-covered services
Because Medicare's 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 Medicare's claims filing rules and limits on charges do not apply to such items or services. For example, because Medicare does not cover hearing aids, an eligible 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 eligible practitioner, or other supplier would not be subject to any Medicare limit on the amount they could collect for the hearing aid.
Where an eligible 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 eligible practitioner is prohibited from submitting claims to Medicare (except for emergency or urgent care services furnished to a beneficiary with whom the eligible practitioner did not have a private contract).
l. Organizations that furnish eligible practitioner services
The opt-out applies to all items or services the eligible practitioner furnishes to Medicare beneficiaries, regardless of the location where such items or services are furnished.
Where an eligible 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 eligible practitioner furnishes to Medicare beneficiaries. However, if the eligible practitioner continues to grant the organization the right to bill and be paid for the services the eligible 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 an eligible practitioner to opt-out of Medicare does not affect the ability of the group practice or organization to bill Medicare for the services of eligible practitioners who have not opted out of Medicare.
Corporations, partnerships, or other organizations that bill and are paid by Medicare for the services of eligible practitioners who are employees, partners, or have other arrangements that meet the Medicare reassignment-of-payment rules cannot opt-out because they are not eligible practitioners. Of course, if every eligible practitioner within a corporation, partnership, or other organization opts out, then such corporation, partnership, or other organization would have, in effect, opted out.
M. Emergency and urgent care situations
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 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 patient's 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 eligible practitioner to provide treatment within 12 hours.
Payment may be made for services furnished by an opt-out eligible 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 eligible practitioner opted out.
Note: A CMS-855I application is required to be submitted before any reimbursement is received.
Where an eligible practitioner who has opted out of Medicare treats a beneficiary with whom the eligible practitioner does not have a private contract in an emergency or urgent situation, the eligible practitioner may not charge the beneficiary 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.
In circumstances where the eligible practitioner must submit a completed Medicare claim on behalf of the beneficiary, the appropriate HCPCS code and HCPCS modifier that indicates the services furnished to the Medicare beneficiary were emergency or urgent must be reported, and the beneficiary does not have a private agreement with the eligible practitioner. If the eligible practitioner did not submit GJ national HCPCS modifier, then the contractor must deny the claim so that the beneficiary can appeal.
GJ = Opt-out eligible practitioner emergency or urgent services
This modifier must be used on claims for services rendered by an opt-out eligible practitioner for an emergency/urgent service. The use of this modifier indicates that the service was furnished by an opt-out eligible 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 eligible practitioner opted out.
N. Renewal of opt-out
An eligible practitioner may renew an opt-out without interruption by filing an affidavit with each contractor to which an affidavit was submitted for the first opt-out, and to each contractor to which a claim was submitted under the emergency or urgent care regulations during the previous opt-out period, provided the affidavits are filed within 30 days after the current opt-out period expires.
Eligible practitioners that sign valid opt-out affidavits on or after June 16, 2015, will no longer be required to file renewal affidavits. Eligible practitioners that file valid opt-out affidavits effective on or after June 16, 2015, and do not want to extend their opt-out status at the end of a two year opt-out period may cancel by notifying all Medicare contractors with which they file an affidavit in writing at least 30 days prior to the start of the next two year opt-out period.
O. Early termination of opt-out
If an eligible practitioner changes his or her mind after the contractor has approved the affidavit, the opt-out may be terminated within 90 days of the effective date of the affidavit. To properly terminate an opt-out, an eligible practitioner must:
Not have previously opted out of Medicare (the eligible practitioner cannot terminate a renewal of his/her opt-out);
Notify all Medicare contractors, with which the eligible practitioner filed an affidavit, of the termination of the opt-out no later than 90 days after the effective date of the opt-out period;
Refund to each beneficiary with whom the eligible practitioner has privately contracted all payment collected in excess of:
The Medicare limiting charge (in the case of physicians or practitioners); or
The deductible and coinsurance (in the case of practitioners).
Notify all beneficiaries (or their legal representation) with whom the eligible practitioner entered into private contracts of the eligible practitioner's decision to terminate opt-out and of the beneficiaries' right to have claims filed on their behalf with Medicare for services furnished during the period between the effective date of the opt-out and the effective date of the termination of the opt-out period.
If the eligible practitioner was previously enrolled to bill Medicare, the practitioner will be reinstated in Medicare as if there had been no opt-out. If the eligible practitioner was not previously enrolled to bill Medicare, he/she can submit the appropriate application(s) to establish a Medicare enrollment record.
P. Cancellation of opt-out
If an eligible practitioner decides to cancel his/her opt-out, the eligible practitioner must submit a written, signed notice to each Medicare administrative contractor to which he/she would file claims absent the opt-out, no later than 30 days before the end of the current 2-year opt-out period.
If the eligible practitioner decides to enroll in Medicare after his or her opt-out is cancelled, the practitioner must submit an application via PECOS or a paper CMS-855I application. The effective date of enrollment cannot be before the cancellation date of the opt-out period.
Q. Opt-out renewal alert letter
An opt-out renewal alert letter will be issued to any eligible practitioners whose opt-out period is set to auto-renew. This letter will be issued at least 90 days prior to the auto-renewal date, so the eligible practitioner has at least 60 days prior to the date a cancellation notice must be submitted to cancel the current opt-out. The opt-out auto-renewal alert letter will provide:
Date the current opt-out period will be auto-renewed.
Date the eligible practitioner will need to submit a cancellation request.
Appeal rights if the eligible practitioner fails to submit a cancellation request and the opt-out renews.
R. Appeal process for opt-out decisions
If an eligible practitioner fails to properly cancel or terminate their opt-out, he/she will be given the opportunity to appeal the decision to continue the auto-renewal or initial opt-out period.
Appeal rights for eligible practitioners that initially opt-out and fail to properly terminate the opt-out within 90 days of approval will be included on the out-out approval letter.
CMS will be conducting the appeal process. Submit your appeal request with any supporting documentation to:
Centers for Medicare and Medicaid Services
Center for Program Integrity
Provider Enrollment and Oversight Group
ATTN: Division of Provider Enrollment Appeals
7500 Security Blvd.
Mailstop: AR-19-51
Baltimore, MD 21244-1850