Opt-Out Physician or Practitioner Providing Emergency or Urgent Care

In an emergency or urgent situation, a physician or practitioner who opts out may treat a Medicare beneficiary with whom they do not have a private contract. In this situation, the physician or practitioner may not charge the beneficiary more than what a nonparticipating physician or practitioner would be permitted to charge and must submit a claim to Medicare on the beneficiary’s behalf.

Payment will be made for Medicare-covered services furnished in emergency or urgent situations when the beneficiary has not signed a private contract with that physician or practitioner.

Modifier GJ ‒ Opt-out physician/practitioner shall be used when billing for emergency and urgent care situations.

Related Content

• Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 40.28

Reviewed 6/18/2024