US · guidance
CMS Pub. 100-02, ch. 15, § 40.37
Application to the Medicare Advantage Program
The Medicare Managed Care Manual contains instructions for Medicare Advantage plans about the impact
on managed care.
The manual provides in general that Medicare Advantage plans:
• Must acquire and maintain information from Medicare contractors on physicians and practitioners
who have opted out of Medicare.
• Must make no payment directly or indirectly for Medicare covered services furnished to a Medicare
beneficiary by a physician or practitioner who has opted out of Medicare, except for emergency or
urgent care services furnished to a beneficiary who has not previously entered into a private contract
with the physician or practitioner, in accordance with §40.28.
The Medicare contractor must maintain mutually agreeable means of advising Medicare Advantage plans of
who has opted out. Disputes with Medicare Advantage plans about the provision of opt out information
should be referred to the regional office staff for resolution.
History
(Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
fc1d422062f01579ca1454678eea140b80a022402a152c91226189573a805a78
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