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Provider Enrollment: Reminder for Open Enrollment and Participation Agreement

The 2023 Annual Participation Open Enrollment Period is approaching for another year. While this is an important time (from mid-November to December 31) for providers to determine if they will become and/or remain participating for the upcoming year, we want to bring some reminders to your attention based on issues we have seen in the past.

The CMS-460 is NOT needed during open enrollment if the:

  • Provider reassigns all Medicare benefits
  • Provider is already participating and will remain participating
  • Nonphysician practitioner is considered mandatory participation

CMS regulations in the CMS Internet-Only Manual (IOM), Medicare Program Integrity Manual, Publication 100-08, Chapter 10, Section state:

  • Individual physicians and nonphysician practitioners who only reassign benefits to a clinic/group practice inherit the participating status established by the clinic/group practice; accordingly, these physicians and nonphysician practitioners need not submit the Form CMS-460.

CMS regulations in the CMS IOM, Medicare Program Integrity Manual, Publication 100-08, Chapter 10, Section 10.6.11 state:

  • Nonphysician practitioners that are considered mandatory participation and individual physicians and nonphysician practitioners that reassign all of their benefits to a participating organization should not be entered as "PAR" in PECOS.

National Government Services receives and returns a great number of unnecessary CMS-460 Participation Agreements every year due to the regulations indicated above.

Please review and share this information with all enrollment professionals within your organization.

Posted 11/8/2022