Medicare Part B 101 Manual

Medicare Part B 101 Manual

Participation Program

Table of Contents

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Eligibility

All practitioners and suppliers eligible to receive payments under Part B of Medicare may choose to enter into a participation agreement. This includes practitioners whose services are subject to mandatory assignment. The reason why it could still be appropriate for such practitioners to enter into a participation agreement is because the mandatory assignment provisions apply only to the particular practitioner service benefit (e.g., nurse practitioner services). For example, if a nurse practitioner is eligible to bill for, and is indeed billing under, Part B for something other than a nurse practitioner service (e.g., an EKG tracing), the mandatory assignment provision of the law does not apply to that other service. However, if the nurse practitioner has entered into a participation agreement, that agreement requires the nurse practitioner to accept assignment for any service submitted to Medicare Part B.

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Participation Enrollment Period/Participating Status Changes

MACs conduct an enrollment period on an annual basis in order to provide eligible practitioners and suppliers with the opportunity to enroll in or terminate enrollment in the participation program. They are given specific instructions each year regarding the dates during which the enrollment period is in effect. As a general rule, during mid-November through the end of December of each year, a provider is offered the opportunity to change their participating status for the following calendar year. The provider’s current participating status will remain in effect unless the MAC receives timely written notification of status change.

To enroll:

Fill out, sign, and date the CMS-460 form and send original agreement, not a copy, to the MAC or if sending initial application through PECOS fill out the PAR topic under the topic view section and fill out sign and date the CMS-460 form and upload with application.

Note: applications will only be accepted with original initial application, during the first 90 days after approval of initial application to a state during the annual enrollment period.

To terminate participation:

Submit an application through PECOS or submit a written request informing terminating participation with Medicare to nonparticipating status and send to the MAC for approval response during the annual enrollment period. (Note: requested change will be in effect January 1st)

Note: If a sole proprietor or entity/supplier with the same SSN/EIN/TIN is enrolling in a new state, PAR status is universal for all the enrollment accounts and a change in status will be confirmed with the MAC.

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Participation Program

Participating Provider

A participating provider is one who voluntarily enters into an agreement to accept assignment for all covered services provided to Medicare patients for the 12-month period beginning January 1st of a particular year and ending December 31st of that year.

Participating agreements are automatically renewed unless cancellation is requested in writing, during the annual enrollment period that is typically mid-November through December 31st for existing enrollments.

The benefits of signing a participation agreement include:

  • The participating fee schedule allowance is five percent greater than the nonparticipating physician fee schedule allowance
  • Participants receive direct and timely reimbursement from Medicare to the billing provider
  • May collect deductible and copayment amounts
  • Beneficiaries with Medigap coverage (private supplemental insurance) may assign the payment on the supplemental claim to the provider or supplier. Under the current mandatory Medigap (claim-based) crossover process, beneficiaries must assign payment on their claims to a participating provider or supplier as a condition for their claims to be forwarded to their Medigap insurer for payment of all coinsurance and deductible amounts due under the Medigap policy. The Medigap insurer, in turn, must pay the participating provider or supplier directly, thereby relieving the need of having to file a second claim. (Refer to the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 28, Section 70.6, for more information regarding the eligibility-file based crossover process.)
  • May appeal a claim determination without written authorization from the Medicare patient
  • In MSP cases, the provider may look to the primary insurer for the full charge
  • Participating Provider Listing in the MEDPARD that is posted on the National Government Services website.

Hospital personnel referring a patient to a nonparticipating physician for further care on an outpatient basis must, where possible, also identify a participating physician from whom the patient may choose to receive necessary services.

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Nonparticipating Provider

A nonparticipating provider may submit a claim as either assigned or as unassigned.

If the claim is submitted as assigned:

  • Payment will be made to provider
  • The provider may only bill the Medicare patient for the deductible and copayment amounts of the Medicare approved allowance (not up to the limiting charge)

If the claim is submitted as unassigned:

  • Payment will be made to the Medicare patient
  • The provider may charge the Medicare patient up to the amount of the limiting charge
  • In MSP cases, the provider who does not accept assignment may not bill or collect more than the limiting charge from anyone or any entity

The physician fee schedule allowance for nonparticipating providers is five percent less than the participating physician fee schedule allowance.

To initiate the appeals process:

  • The provider must have written authorization from the Medicare patient, or
  • Payment was denied or reduced due to medical necessity guidelines, the denial is subject to limitation of liability and the provider is liable for the denial or payment reduction, i.e., the provider failed to obtain a valid ABN and, therefore, may not seek payment from the Medicare patient

A nonparticipating provider is limited in what is charged (referred to as limiting charge) for covered services rendered to a Medicare patient.

Nonparticipating physicians performing elective surgery on an unassigned basis must, in writing, provide certain fee information to the Medicare patient, prior to surgery, if the charge is $500 or more. If this information is not given to the Medicare patient, the nonparticipating physician is limited to the Medicare approved amount and the patient liability is the deductible and co-payment of the approved amount.

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When Physicians Work for a Hospital or Medical Group

The following rules apply when physicians work for (or are members of) a hospital, medical group or other entity:

  • Except in the case of university medical centers, if a hospital, medical group, or other entity bills and receives payment for physician services in the name of the entity (rather than have the individual physicians bill and receive payment in their own names), one participation agreement by the entity binds all physicians with respect to any services furnished for the entity. In this situation, the individual physicians do not enter into participation agreements.

Note: In university medical centers, when individual departments bill under the name and provider identification number of the department, decisions for or against participation can be made on a departmental basis.

  • If a physician who is associated with a particular entity has an individual practice outside the scope of the practice for which the entity bills and receives payment, they may choose whether to participate with respect to their outside practice without regard to the participation status of the entity.
  • If individual physicians who work for an entity bill and receive payment in their own names for the services furnished for the entity, they make individual decisions as to whether to participate. These decisions apply both to the physicians services for the entity and to any outside practice.

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Services Subject to Agreement

The participation agreement applies to items and services for which payment is made on a fee-for-service basis by the Medicare Part B contractor. A participating agreement applies to all items and services in all states and under all names and identification numbers under which the participant does business.

If the participant opens offices in another MAC jurisdiction during the term of the agreement, a photocopy of the agreement must be filed with that MAC.

The participant lists all names and identification numbers under which the participant submits claims to the MAC. This means all names and numbers of the legal entity entering into the agreement, whether that entity is a sole proprietorship, partnership or corporation.

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When New Physician/Supplier in Area May Enter Into Agreement

A physician/supplier who has enrolled in the Medicare Program and wishes to become a participating physician/supplier must file an agreement with a MAC within 90 days after either of the following events:

  • The participant is newly licensed to practice medicine or another health care profession, or
  • The participant first opens offices for professional practice or other health care business in a particular MAC service area or locality (regardless of whether the participant previously had or retains offices elsewhere)

If a physician has an arrangement with a hospital, medical group, or other entity under which the entity bills in its name for services, changes that arrangement and then begins to bill in their own name, they are considered to be first opening office, even though they practice in the same location.

The participating enrollment package is included with the CMS-855 form for new enrollees. When the agreement is filed on one of the above bases, it is effective on the date of filing, i.e., the date the participant mails (postmark date) or delivers the agreement to the MAC. The initial period of the agreement may be less than 12 months. Otherwise, the terms of the agreement are the same as those of an agreement entered into by other physicians or suppliers. The agreement applies to all services in all localities. The physician or supplier must submit the original agreement to the MAC in their region and photocopies to all other MACs with whom he or she deals.

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Mandatory Assignment

Some practitioners who provide services under the Medicare program are required to accept assignment for all Medicare claims for their services. This means that they must accept the Medicare allowed charge amount as payment in full for their practitioner services. The beneficiary’s liability is limited to any applicable deductible plus the 20 percent coinsurance. The practitioners’ services to which mandatory assignment applies include:

  • Clinical diagnostic laboratory services and physician lab services
  • Physician services to individuals dually entitled to Medicare and Medicaid
  • Ambulatory surgical center services
  • Drugs and biologicals
  • Ambulance services
  • Physician assistants
  • Nurse practitioners
  • Clinical nurse specialists
  • Clinical psychologists
  • Clinical social workers
  • Marriage Family Therapists
  • Mental Health Counselors
  • Certified registered nurse anesthetists
  • Nurse midwives
  • Registered dietitians/nutritionists
  • Anesthesiologist assistants, and
  • Mass immunization roster billers

Note: Mass immunization roster billers can only bill for influenza, pneumococcal and COVID-19 vaccinations and administrations. These services are not subject to the deductible or the 20 percent coinsurance.

Note: Practitioners with mandatory assignment are not listed in the MEDPARD Directory unless submitted Form CMS-460 upon initial enrollment or during annual open enrollment.

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Revised 2/26/2024