Key Points/Instruction/What you need to know
| Participating Provider |
Non-Participating Provider |
| A participating provider is one who voluntarily and in advance enters into an agreement in writing to provide all covered services for all Medicare Part B beneficiaries on an assigned basis. |
A non-participating provider has not entered into an agreement to accept assignment on all Medicare claims. |
| Agrees to accept Medicare-approved amount as payment in full. |
Can elect to accept assignment or not accept assignment on a claim-by-claim basis. |
| May not collect more than applicable deductible and coinsurance for covered services from patient. Payment for non-covered services may also be collected. |
If the provider performs elective surgery costing more than $500, the beneficiary must be notified in writing of the expected financial responsibility. |
| Charges are not subject to limiting charge. |
Cannot bill the patient more than the limiting charge on non-assigned claims. (DC, DE, MD, NJ, City of Alexandria, VA, Counties of Arlington and Fairfax in VA) |
| Medicare payment paid directly to the provider. |
Pennsylvania’s Medicare Overcharge Measure prevents non-participating physicians from charging patients more than the Medicare allowance. Therefore, PA providers cannot bill the patient more than the Medicare approved amount on non-assigned claims. |
| Mandatory claims submission applies. |
Beneficiary receives payment on non-assigned claims. |
| Placement in Medicare Participating Physicians and Suppliers Directory (MEDPARD). |
Mandatory claims submission applies. |
| Reimbursement is 5 percent higher than the non-participating amount. |
Clinical laboratory services and drugs and biologicals must be billed as assigned. |
| Medigap information is transferred. |
Approved amount is 5 percent less than participating — even if assignment is accepted on the claim. |
| Patient referral service by hospital. |
Medigap information is not transferred. |
To be a participating provider under Medicare, you must be in compliance with the applicable provisions of title VI of the Civil Rights Act of 1964 and must enter into an agreement under §1866 of the Act which provides that you: (1) will not charge any individual or other person for items and services covered by the health insurance program other than allowable charges and deductibles and coinsurance amounts; and (2) will return any money incorrectly collected from the beneficiary or other person on their behalf or make such other disposition that would cause a termination of your agreement.
Toward the end of each calendar year there is an open enrollment period. The open enrollment period generally is from mid-November through December 31. During this period, if you are enrolled in the Medicare Program, you can change your current participation status beginning the next calendar year on January 1. This is the only time you have the opportunity to change your participation status.
New physicians, practitioners, and suppliers can sign the participation agreement and become a Medicare participant at the time of enrollment into the Medicare Program. The participation agreement will become effective on the date of filing; i.e., the date the participant mails (post-mark date) the agreement to the Medicare Administrative Contractor (MAC) or delivers it to the MAC.
PHYSICIAN, PRACTITIONER OR SUPPLIER CURRENTLY ENROLLED:
If you choose to participate:
• Do nothing if you are currently participating, or
• If you are not currently a Medicare participant, complete the blank agreement (CMS-460) and mail it (or a copy) to each MAC to which you submit Part B claims. (On the form show the name(s) and identification number(s) under which you bill.)
If you decide not to participate:
• Do nothing if you are currently not participating, or
• If you are currently a participant, write to each MAC to which you submit claims, advising of your termination effective the first day of the next calendar year. This written notice must be postmarked prior to the end of the current calendar year.
NEW PHYSICIAN, PRACTITIONER OR SUPPLIER:
If you choose to participate:
• Complete the blank agreement (CMS-460) and submit it with your Medicare enrollment application.
• If you have already enrolled in the Medicare program, you have 90 days from when you are enrolled to decide if you want to participate. If you decide to participate within this 90-day timeframe, complete and submit the CMS-460.
If you decide not to participate:
• Do nothing. All new physicians, practitioners, and suppliers that are newly enrolled are automatically non-participating. You are not considered to be participating unless you submit the CMS-460 form.
