The Medicare participation program involves a voluntary agreement between a supplier and Medicare. Under the agreement, the supplier agrees to accept assignment for all services rendered to Medicare beneficiaries and to accept the Medicare allowed amount as the total charge for any covered item.

Any Medicare-enrolled supplier may choose to participate in the program. Participation is not automatic; the assignment of a durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) Provider Transaction Access Number (PTAN) does not enroll a supplier in the program. A separate participation agreement, the CMS-460 form , must be filed with the National Supplier Clearinghouse (NSC).

Once a supplier is enrolled in the program, the agreement applies to locations enrolled under the same tax identification number. Participation is not location specific. This is true whether the supplier is an individual, partnership or corporation.

Enrollment
The participation enrollment form is available on the NSC Web site or on the Centers for Medicare & Medicaid Services (CMS) Web site .

Suppliers may also obtain an enrollment form by calling the NSC toll free at 866-238–9652, or by writing to:

National Supplier Clearinghouse
Palmetto GBA—AG-495
P.O. Box 100142
Columbia, South Carolina 29202-3142

If preferred, suppliers can e-mail their questions to Medicare.NSC@PalmettoGBA.com. Questions received will be answered within a reasonable time frame. The NSC suggests that suppliers refrain from submitting protected healthcare information via e-mail.

The Centers for Medicare & Medicaid Services (CMS) offers an open enrollment period each year when suppliers may enroll in the program or provide notice of the termination of their participation agreement. The open enrollment period usually takes place mid-November to the end of December. The NSC notifies suppliers of the specific dates for the enrollment period each year.

In order to terminate a participation agreement, a supplier must notify the NSC in writing during the enrollment period. The written notice must be postmarked before the end of the enrollment period and have the original signature of the authorized official. The termination will be effective January 1 of the following year.

The NSC will acknowledge receipt of a request, which has been completed appropriately and has the proper original signature, to enroll or to terminate enrollment in the participation program. Suppliers who do not receive an acknowledgement within a reasonable time should contact the NSC.

Benefits of Participation
By agreeing to accept assignment on all claims, a participating provider receives certain advantages. By accepting assignment, a supplier:

• requests direct payment from Medicare for covered items;
• accepts the Medicare allowed amount as the full charge for the item or service; and
• has the right to appeal claim determination by the durable medical equipment Medicare administrative contractor (DME MAC).

Medicare also advertises the participation status of providers to beneficiaries by providing a directory of participating providers to senior citizens groups and, upon request, to individual Medicare beneficiaries.

Medicare provides for the automatic crossover of claims to Medigap insurers for participating providers. In other words, when a participating supplier provides the appropriate information on a claim for a beneficiary who has a Medigap insurance policy, Medicare will transfer the claim information to the Medigap insurer after processing, reducing paperwork for the supplier. Refer to the Claim Submission chapter of this manual for CMS-1500 claim form completion instructions to ensure automatic crossover.

Assignment of Claims
It should be noted that the terms participating and nonparticipating refer to suppliers. The terms assigned and nonassigned refer to claims.

By accepting assignment on a claim a supplier agrees to accept Medicare’s allowed amount as the full charge for the items or services provided. This means that for covered services, the supplier may collect only the deductible and remaining coinsurance amounts from the beneficiary. A claim for an assigned item is considered paid in full when the DME MACs allowed amount is paid.

On an assigned claim that was denied because the beneficiary did not meet Medicare’s medical necessity criteria, the beneficiary may be held financially responsible for Medicare’s allowed amount if an acceptable Advance Beneficiary Notice (ABN) was obtained. Refer to the Advanced Beneficiary Notice of Noncoverage chapter for detailed information regarding ABN requirements.

For noncovered items, the beneficiary may be held financially responsible for the supplier’s entire charge regardless of whether the claim is filed assigned or nonassigned.

Assignment for Nonparticipating Suppliers
Suppliers who have not enrolled in the participation program (i.e., nonparticipating suppliers) may accept assignment on a claim-by-claim basis. On a nonassigned claim that was denied because the beneficiary did not meet Medicare’s medical necessity criteria, the beneficiary may be held financially responsible for the supplier’s entire charge if an acceptable ABN was obtained prior to rendering the services.

A nonparticipating supplier may not file assigned claims for some items and nonassigned claims for other items when they were provided to the same beneficiary on the same date.

Once a claim has been filed as assigned, it may not be changed to nonassigned without the consent of both the beneficiary and the supplier. The notice to rescind must be received by the DME MAC prior to payment determination.

Assignment Violation
When an assignment violation is noted by the DME MAC through the review of a claim or through a beneficiary complaint, the DME MAC will educate the supplier on the terms of the assignment agreement. The supplier may be required to return a refund and provide a corrected statement to the beneficiary.

Where there are repeated violations of the assignment agreement, the DME MAC may suspend further payment to the supplier on assigned claims as directed by the CMS. For payable claims, payment will be made directly to the beneficiary. The beneficiary will be advised that the supplier has not complied with the requirements for receiving payment from Medicare.