PECOS Exemption for Medicare
Opted-Out Physicians with NPI#

The Federal Register states that "We require that [opted-out physicians] be identified in claims by their names and their NPIs if they order or refer covered items or services for Medicare beneficiaries.... A physician or eligible professional who has validly opted out of the Medicare program will have a valid opt-out record in PECOS and is not required to submit an enrollment application."

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*Federal Register /Vol. 75, No. 86 /Wednesday, May 5, 2010 /Rules and Regulations p. 24443

"Under section 1802(b) of the Act and
the implementing regulations at 42 CFR
405.400 et seq., physicians and nonphysician
practitioners can opt out of
the Medicare program and enter into
private contracts with Medicare
beneficiaries. By entering into these
types of contracts, these suppliers do
not bill the Medicare program for
services that they furnish to Medicare
beneficiaries. We require that
physicians and eligible professionals
who have properly filed an appropriate
affidavit with a Medicare contractor in
order to opt out of the Medicare
program be required to be identified in
claims by their names and their NPIs if
they order or refer covered items or
services for Medicare beneficiaries. We
are creating an exception to the
requirement that ordering and referring
suppliers be required to have an
approved enrollment record in PECOS
for those physicians and non-physician
practitioners who have validly opted
out of the Medicare program. Therefore,
physicians and non-physician
practitioners who have validly opted
out of Medicare are eligible to order and
refer covered items and services for
Medicare beneficiaries. If they have
properly completed the appropriate
affidavit in order to opt out of Medicare,
they will have records in PECOS that
contain their NPIs and that indicate that
they have validly opted out of the
Medicare program. In January 2009,
there were approximately 10,000
physicians and eligible professionals
who had opted out of the Medicare
program. Compared to the more than
800,000 enrolled physicians and eligible
professionals, there are relatively few
physicians and eligible professionals
who have opted out of Medicare.
Accordingly, the physicians or
eligible professional that opted out must
meet the following:
 A currently enrolled physician or
eligible professional who does not have
an enrollment record in PECOS is
required to establish an enrollment
record in PECOS so that he or she can
order and refer covered items or services
for Medicare beneficiaries. A physician
or eligible professional who has validly
opted out of the Medicare program will
have a valid opt-out record in PECOS
and is not required to submit an
enrollment application."*