A provider who has opted out of Medicare generally cannot bill Medicare for services furnished to Medicare beneficiaries. The provider may only submit Medicare claims for emergency or urgent care services furnished to a Medicare beneficiary with whom the provider does not have a private contract.

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 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 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.

To bill Medicare for emergency or urgent care services, the provider must be enrolled. The provider should submit an enrollment application through PECOS or submit a paper CMS-855I. Once the Provider Transaction Access Number (PTAN) is issued, the provider must submit claims for any emergency or urgent care services provided.

The CMS-855I should be submitted no later than 30 days after the service occurred so the Medicare Administrative Contractor (MAC) can honor the effective date. In these situations, the MAC may coordinate with CMS for guidance and work with the provider to set up the PTAN. For more information, refer to CMS Internet-Only Manual (IOM) Publication 100-08, Medicare Program Integrity Manual, Chapter 10, Section 10.6.12.

Ordering and Referring

An opt-out affidavit and an active CMS-855O enrollment for ordering or referring cannot be in effect at the same time.