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Medicare Opt-Out Providers


Provider Administrative Policy

Section
Claims Submission
Policy Date
July 2009
Status/Date
New/June 2012
Provider Type(s)
All Providers  

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.

Policy

Medicare Opt-Out Providers

The Medicare Beneficiary Act of 1997 allows physicians to enter into private contracts with Medicare beneficiaries to provide covered Medicare Part B services. Commonly called the Medicare Opt-Out Act, the beneficiary agrees to waive Medicare payment for services provided by the physician or practitioner and further agrees to pay the provider without regard to any pricing limitations that would otherwise apply. The law also explicitly states that the patient must pay the entire fee charged by the physician for these services and the physician may not bill Medicare. This law affects only services covered by Medicare and will affect all Medicare patients the provider has. Both the provider and the Medicare beneficiary must sign an opt out affidavit. Neither the provider nor the Medicare beneficiary may submit these claims to Medicare or receive payment from Medicare for these claims.
           
Exception: In some circumstances, opt-out providers can bill Medicare for services performed in a medical emergency. If a Medicare EOB is attached it is okay to coordinate.

Coordination with Medicare:
When a claim is received with a Medicare opt-out statement on a member who has Medicare primary and a Blue Cross of Idaho group, individual or Medicare carve out policy as second, the claim can be processed as if Blue Cross of Idaho is primary. The member`s contract benefits apply. Allowed amount is the lesser of 20 percent of billed charge or 20 percent of Blue Cross of Idaho maximum allowable. Payment will be made to either the member or the provider based on the provider`s contracting status with Blue Cross of Idaho.

Medicare Supplements:
When a provider opts out of Medicare it presents a few problems for processing Medicare supplement claims. Normally Medicare supplement contracts: 

  • Require a Medicare EOB to process. These claims will have no Medicare EOB. 
  • Do not cover any services not covered by Medicare. Medicare will not pay for these services even though they are covered services.

When a claim is received with a Medicare opt-out statement on a member who has a Medicare supplement policy as second, Blue Cross of Idaho is responsible for paying the lesser of 20 percent of billed charge or 20 percent of Blue Cross of Idaho maximum allowable. Payment will be made to the member since the provider does not accept Medicare assignment.  


Policy History

Date Action Reason
June 2012 Revised Transparent language revision

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