CMS Pub. 100-04, ch. 1, § 30.3.13

Charges for Missed Appointments

(Rev. 3510, Issued: 04-29-16, Effective: 10-01-16, Implementation; 10-03-16)

CMS's policy is to allow physicians and suppliers to charge Medicare beneficiaries for

missed appointments, provided that they do not discriminate against Medicare

beneficiaries but also charge non-Medicare patients for missed appointments. The charge

for a missed appointment is not a charge for a service itself (to which the assignment and

limiting charge provisions apply), but rather is a charge for a missed business

opportunity. Therefore, if a physician's or supplier's missed appointment policy applies

equally to all patients (Medicare and non-Medicare), then the Medicare law and

regulations do not preclude the physician or supplier from charging the Medicare patient

directly.

The amount that the physician or supplier charges for the missed appointment must apply

equally to all patients (Medicare and non-Medicare), in other words, the amount the

physician/supplier charges Medicare beneficiaries for missed appointments must be the

same as the amount that they charge non-Medicare patients (whatever amount that may

be).

With respect to Part A providers, in most instances a hospital outpatient department can

charge a beneficiary a missed appointment charge without violating its provider

agreement and 42 CFR 489.22. Because 42 CFR 489.22 applies only to inpatient

services, it does not restrict a hospital outpatient department from imposing charges for

missed appointments by outpatients. In the event, however, that a hospital inpatient

misses an appointment in the hospital outpatient department, it would violate 42 CFR

489.22 for the outpatient department to charge the beneficiary a missed appointment fee.

Medicare does not make any payments for missed appointment fees/charges that are

imposed by providers, physicians, or other suppliers. Charges to beneficiaries for missed

appointments should not be billed to Medicare.

The contractor shall use the following remittance advice messages and associated codes

when rejecting/denying claims under this policy. This CARC/RARC combination is

compliant with CAQH CORE Business Scenario Three.

Group Code: PR

CARC: 204

RARC: N/A

MSN: 16.59