NPI/Medicare

[jessieMarina]

I work for a group practice and two of the three physicians have opted out of Medicare.  The 3rd physician has not opted out, but has not enrolled either.  I'm guessing he is considred an out of network provider.  I have submitted claims for him on multiple times and Noridian keeps sending me th same letter:
Medicare is unalbe to process the claims because the NPI in Item 33a and/or Item 24j was blank, unreadable or invalid.  The NPI was listed and I do not know what else to do.  The practice NPI did not opt out of Medicare just the 2 other individual physicians.  Do I submit the claim under the physician only and not the Group, I'm so confused...

[Merry]

You must report the rendering provider on the claim. If the provider had never enrolled in Medicare then it cannot be billed.  There is a difference in opt out and not enrolled.  Opt out is a process
that lasts for 2 years where neither the provider nor the patient can bill Medicare for services.  There is also
par and non par so important to
understand all the definitions. 
I have never heard of using the term out of network for Medicare.  You can only bill for Medicare services if the provider is enrolled as a par or non par provider.  I suspect you are using the drs NPI number but since he is not enrolled,  it is not being recognized by the Medicare system.  You cannot bill for the services that he provided.  Did the practice accept the patient as a Medicare patient?  Seems to me that with three providers.. 2 opt out and 1 not enrolled that you cannot see Medicare patients at all. 

Merry