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Last Modified: 9/28/2022 Location: FL, PR, USVI Business: Part B

Do you know the benefits of participation in Medicare versus non-participation?

Participating provider versus non-participating provider

Participating provider
Non-participating provider
Enters into an agreement in writing to provide all covered services for all Medicare Part B beneficiaries on an assigned basis
Agrees to accept Medicare-approved amount as payment in full
May not collect more than applicable deductible and coinsurance for covered services from patient
Payment for non-covered services may also be collected
Medicare payment paid directly to the provider
Mandatory claims submission applies
Placement in Medicare Participating Physicians and Suppliers Directory (MEDPARD)
Allowed at 100% of physician fee schedule
Medigap information is transferred
Does not enter into an agreement to accept assignment on all Medicare claims
Can elect to accept assignment or not accept assignment on claim-by-claim basis
Cannot bill the patient more than the limiting charge on non-assigned claims
Beneficiary receives payment on non-assigned claims
Mandatory claims submission applies
Clinical laboratory services and drugs and biologicals must be billed as assigned
Allowed at 95% of physician fee schedule
Medigap information is not transferred
When can I change my participation status?
Toward the end of each calendar year there is an open enrollment period, generally from mid-November through December 31. During this period, if you’re enrolled in the Medicare Program, you can change your current participation status beginning Jan. 1 of the next calendar year. The open enrollment period is the only opportunity to change your participation status.
New physicians, practitioners, and suppliers can sign the participation agreement at the time of enrollment and become a Medicare participating provider in the Medicare Program. The participation agreement will become effective on the date of filing (i.e., the date the participant mails [postmark date] the agreement to the MAC).
If you participate in the Medicare program, you must accept assignment on all claims. Non-participating providers can elect to accept assignment or not accept assignment on a claim-by-claim basis. While you make this decision upon initial enrollment or during the open enrollment period, there are providers that are required to accept assignment.
Medicare requires the following practitioners accept assignment for all services rendered to Medicare beneficiaries:
Physician assistant
Nurse practitioner
Certified registered nurse anesthetist
Clinical nurse specialist
Certified nurse midwife
Clinical social worker
Clinical psychologist
Registered dietician/nutrition professional
Anesthesiologist assistant
Mass immunization roster billers
Because these practitioners must accept assignment on claims, it is not necessary to complete a participation agreement when enrolling in the Medicare program.

Resources

First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.