Opt Out Services and Management - JF Part B

This section covers guidelines for activities after the initial opt out request is processed.

If you need assistance, reach out to our Provider Enrollment Contact Center.

• Renewal of Opt Out Status
• Cancellation of Opt Out Status
• Early Termination
• Appeals
• Emergency Services
• Mailing Addresses

Renewal of Opt Out Status

• Current opt out providers are automatically renewed every two (2) years.
• Notification letters will be sent roughly 90 days before the opt out is due to renew. The letter advises that the opt out will be renewed shortly.
• If the provider wishes to terminate your auto-renewal, he/she must submit the cancellation request via a letter 30 days before the opt out is due to expire.

Cancellation of Opt Out Status

If a provider wishes to end his/her opt out status and reenroll in Medicare, he/she must submit the cancellation request via a letter 30 days before the opt out is due to expire. If the cancellation letter is submitted after the 30 days, he/she will remain opted out for another 2-year cycle. This must be mailed in.

Early Termination

• A provider's opt out status may be voluntarily terminated within 90 days of the affidavit if a provider has not previously been in an opt out status.
• This only applies to initial opt out providers. This does not apply to providers who renew their opt out status
• All previous enrollments with Medicare will be reactivated at the time of the termination of the opt out period.

Appeals

Opt outs can be reconsidered (Appealed). This request must be sent to CMS. If the opt out is sent to Noridian, we will return the opt out advising it will need to be sent to CMS. This must follow the guidelines below:

• Be requested in writing within 60 calendar days of the postmark date of the notification letter (or within 60 calendar days after the 90-day period to terminate ends) and mailed to the address listed therein.
• State the issues or findings of fact with which you disagree and the reasons for disagreement.
• Be signed by the eligible practitioner or an authorized legal representative.
  • If the authorized legal representative is an attorney, the attorney's statement that he or she has the authority to represent the provider or supplier is sufficient to accept this individual as the legal representative.
• If the authorized legal representative is not an attorney, the eligible practitioner must file written notice of the appointment of its representative with the submission of reconsideration request.

Emergency Services

• If a provider has elected to Opt Out of Medicare, they cannot bill for any current patients or clients for any reason except for emergency situations.
• Example of emergencies:
  • Provider assists in a car accident for an unknown victim
  • Provider assists in providing services after a natural disaster
• In order to bill for these services, the provider will need to fully enroll.
  • Submit an application for enrollment via the Provider Enrollment Chain and Ownership System (PECOS) or a paper CMS-855I application.
  • Once the Provider Transaction Access Number (PTAN) has been received, claims must be submitted for any emergency or urgent care service(s) provided.
  • Keep in mind the timeliness requirements, which typically require submission of the 855I no later than 30 days after the service occurred, in order for the Noridian to honor the effective date.
  • Noridian will work with CMS for guidance when this type of situation arises and work with the eligible practitioner to get their PTAN set up.
• Refer to CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 10, Section 10.6.12 for more information on Emergency and Urgent Care Services.