Participation Information

Having a Medicare provider number allows you to bill the Medicare program and receive payment for covered services, but it does not automatically designate you as a “participating” provider within the Medicare program. Medicare’s meaning of “participation” is different from the meaning it has in most private plans.  In Medicare, “participation” means you agree to always accept assignment of claims for all services you furnish to Medicare beneficiaries. By agreeing to always accept assignment, you agree to always accept Medicare allowed amounts as payment in full and to not collect more than the Medicare deductible and coinsurance from the beneficiary. Unlike many private insurance plans, Medicare law requires you to submit claims for Medicare beneficiaries whether you participate or not.

If you choose not to become a participating provider in the Medicare program, you may choose either to accept or not accept assignment on Medicare claims on a claim-by-claim basis. If you choose not to accept assignment, you may not charge the beneficiary more than the Medicare limiting charge for unassigned claims for Medicare services.

Whether enrolling as a new provider, or re-enrolling due to a change of tax ID, providers become non-participating by default. If you do not wish to become a participating provider at the time of enrollment, you have 90 days from the date of your Provider Transaction Access Number (PTAN) notification to change your participation status.  If a participation agreement is received within 90 days of enrollment, the participation effective date will be the postmark date on the envelope.

It is recommended that providers and suppliers review all pertinent information before making a decision regarding participation status.

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