Excluded Physicians and Practitioners

40.15 - Excluded Physicians and Practitioners (Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13) An excluded physician or practitioner may opt out of Medicare by submitting the required documentation in accordance with §40.9. When determining effective dates of the exclusion versus the opt-out, the date of exclusion always takes precedence over the date the physician or practitioner opts out of Medicare. A physician or practitioner who has been excluded must comply with 42 CFR 1001.1901, “Scope and Effect of Exclusion.” If an excluded/opt-out physician or practitioner submits a claim to Medicare, the Medicare contractor must not make payment for services furnished, ordered, or prescribed on or after the effective date of the exclusion, except in the limited circumstances stated in 42 CFR 1001.1901. The Medicare contractor must not make payment to a beneficiary who submits claims for services rendered by an excluded/opt-out physician or practitioner (except where payment would otherwise be made in accordance with the Medicare Program Integrity Manual). It must deny the claim and send the physician or practitioner the appropriate remittance and send the beneficiary a MSN as explained in §40.39.