The Federal Register states that “We require that
[opted-out physicians] be identified in
claims by their names and their NPIs if
they order or refer covered items or
services for Medicare beneficiaries…. A physician
or eligible professional who has validly
opted out of the Medicare program will
have a valid opt-out record in PECOS
and is not required to submit an
enrollment application.”
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*Federal Register /Vol. 75, No. 86 /Wednesday, May 5, 2010 /Rules and Regulations p. 24443
"Under section 1802(b) of the Act and the implementing regulations at 42 CFR 405.400 et seq., physicians and nonphysician practitioners can opt out of the Medicare program and enter into private contracts with Medicare beneficiaries. By entering into these types of contracts, these suppliers do not bill the Medicare program for services that they furnish to Medicare beneficiaries. We require that physicians and eligible professionals who have properly filed an appropriate affidavit with a Medicare contractor in order to opt out of the Medicare program be required to be identified in claims by their names and their NPIs if they order or refer covered items or services for Medicare beneficiaries. We are creating an exception to the requirement that ordering and referring suppliers be required to have an approved enrollment record in PECOS for those physicians and non-physician practitioners who have validly opted out of the Medicare program. Therefore, physicians and non-physician practitioners who have validly opted out of Medicare are eligible to order and refer covered items and services for Medicare beneficiaries. If they have properly completed the appropriate affidavit in order to opt out of Medicare, they will have records in PECOS that contain their NPIs and that indicate that they have validly opted out of the Medicare program. In January 2009, there were approximately 10,000 physicians and eligible professionals who had opted out of the Medicare program. Compared to the more than 800,000 enrolled physicians and eligible professionals, there are relatively few physicians and eligible professionals who have opted out of Medicare. Accordingly, the physicians or eligible professional that opted out must meet the following: • A currently enrolled physician or eligible professional who does not have an enrollment record in PECOS is required to establish an enrollment record in PECOS so that he or she can order and refer covered items or services for Medicare beneficiaries. A physician or eligible professional who has validly opted out of the Medicare program will have a valid opt-out record in PECOS and is not required to submit an enrollment application."*
