CMS Pub. 100-02, ch. 15, § 40.13

For a physician/practitioner who has never enrolled in the Medicare program and wishes to opt-out of

Medicare, if the physician/practitioner does not have an NPI, then the physician/practitioner must include his

or her TIN on the opt-out affidavit. The Medicare contractor must annotate its in-house provider file that the

physician/practitioner has opted out of the program. The Medicare contractor can get the full name, address,

license number, and tax identification number from the physician’s/practitioner’s opt-out affidavit. All other

data requirements should be developed from other data sources (e.g., the American Medical Association,

State Licensing Board, etc.). The physician/practitioner must not receive payment during the opt-out period

(except in the case of emergency or urgent care services). If the Medicare contractor needs additional data

elements and cannot obtain that information from another source, it may contact the physician/practitioner

directly. It must notify the physician or practitioner that in order to certify or order services for a Medicare

patient, the physician or practitioner must have a valid NPI.

If an opt-out physician/practitioner provides emergency or urgent care service to a beneficiary who has not

signed a private contract with the physician or practitioner and the physician/practitioner submits an

assigned claim, the physician or practitioner must complete Form CMS-855-I and enroll in the Medicare

program before receiving reimbursement. Under a similar circumstance, if the physician or practitioner

submits an unassigned claim, the Medicare contractor must pay the beneficiary directly without requiring a

completed Form CMS-855-I. It may use the information from the affidavit to begin the enrollment process.