Claims Denial Notices to Opt-Out Physicians and Practitioners

40.38 - Claims Denial Notices to Opt-Out Physicians and Practitioners (Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16) To ensure that the notice denying payment to the opt-out physician or practitioner indicates the proper reason for denial of payment, the Medicare contractor must include language in the notice appropriate to particular circumstances as follows: • When the claim is submitted inadvertently by the opt-out physician/practitioner, the Medicare contractor must use claim adjustment reason code 27 (expenses incurred after coverage terminated) at the claim level with group code PR (patient responsibility) and the remark code MA47: Our records show that you have opted out of Medicare, agreeing with the patient not to bill Medicare for services/tests/supplies furnished. As a result, we cannot pay this claim. The patient is responsible for payment.” • The Medicare contractor uses the following message when the claim is submitted knowingly and willfully by the opt-out physician/practitioner. It must use claim adjustment reason code 27 (expenses incurred after coverage terminated) at the claim level with group code PR (patient responsibility) and the remittance advice remark code MA47 N771 : Our records show that you have opted out of Medicare, agreeing with the patient not to bill Medicare for services/tests/supplies furnished. As a result, we cannot pay this claim. The patient is responsible for payment. Alert: Under Federal law you cannot charge more than the limiting charge amount.