When a supplier enrolls with Medicare, they have the option of becoming a participating or a non-participating provider. Participation status is part of the enrollment process through the National Supplier Clearinghouse.
Participation means the supplier always agrees to accept assignment for all services furnished to Medicare beneficiaries during a 12-month period, beginning January 1 of each year. By agreeing, the supplier always accepts the Medicare allowed amount as payment in full and doesn’t collect more than the deductible and coinsurance from the beneficiary. By accepting assignment, payment is sent to the supplier.
Suppliers who choose not to sign the participation contract are referred to as non-participating suppliers. For non-participating suppliers, the Medicare payment is sent to the beneficiary. The non-participating supplier can then bill the patient for the difference between the submitted amount and the Medicare allowed amount, as well as the deductible and coinsurance on non-assigned claims. The non-participating supplier can choose on a claim by claim basis whether or not to accept assignment, except where CMS regulations require mandatory assignment, i.e., Medicare covered drugs, home dialysis equipment and supplies, Indian Health Services.
Suppliers who do not accept assignment may continue to request payment in full at the time that the service is provided if the claim for this service is unassigned. It is encouraged to file the claims about the same time that payment is requested. By not accepting assignment of Medicare benefits, suppliers are not a party to the Medicare payment transaction between Medicare and the Medicare beneficiary.
CLAIMS FILING
ASSIGNED – The supplier must accept Medicare allowable in full (80% + 20%
co-pay) – accept nothing more/nothing less on the claim. Note: Failure to
file an assigned claim as a participating supplier will be viewed as
non-compliant with supplier standards and be subject to revocation of the
associated NPI (National Provider Identifier).
NON-ASSIGNED – The supplier accepts payment from the beneficiary upfront. The Medicare check is sent directly to the beneficiary. The supplier will file the claim for the beneficiary but not be directly involved in the monetary transaction between the beneficiary and Medicare.
A supplier’s participation status refers to whether they wish to accept assignment on claims or not. It is not, in any way, referring to whether the supplier wishes to participate in the Medicare program. You may still bill Medicare if you do not choose to sign a participation agreement.
Remember: Participating/non-participating refer to suppliers; assigned/non-assigned refer to claims.
It is important to note participation status is associated with an entity via tax ID number and not a location. A business entity with multiple locations under the same tax ID number cannot choose to have different participation statuses for each location. All locations will automatically be assigned the same status depending what the entity has chosen. This is true whether the supplier is an individual, partnership or corporation.
The participation enrollment form is available on the NSC website and CMS website. An enrollment form may also be obtained from the NSC by calling the toll-free number 866-238-9652 or by writing to the NSC. New suppliers, who have not previously submitted a participation agreement, have up to 90 days after the date its number is assigned to choose to participate. If a supplier does nothing, they will be listed as nonparticipating.
Prior to the open enrollment period, which is usually between mid-November
and the end of December, the NSC will send a letter and an open enrollment
form (CMS-460,
Participation Agreement Form) to each active supplier on file. One letter
and agreement will be sent per tax ID number to the mailing address on the
supplier file.
If an existing non-participating supplier wants to become participating, then
the agreement form must be received during open enrollment and postmarked
before December 31 of that year.
If a participating supplier wants to become nonparticipating, they can request to become non-participating by sending the request to the NSC on their company letterhead. The request must be postmarked before December 31 of that year to become non-participating effective January 1 of the next year.
The CMS-460 form should not be sent to CMS. It must be sent to the NSC. Sending it to CMS will delay processing of the form.
| NSC Address National Supplier Clearinghouse Palmetto GBA AG-495 P.O. Box 100142 Columbia, SC 29202-3142 |
NSC Overnight Mailing Address National Supplier Clearinghouse Palmetto GBA AG-495 2300 Springdale Drive, Bldg. 1 Camden, SC 29020 |
Keep in mind that certain advantages or incentives are in place for suppliers to become participating in the Medicare program.
- Providers receive direct and timely reimbursement from Medicare;
- For Medicare Part B services, participants have automatic “one stop” billing for beneficiaries who have Medigap coverage not connected with their employment and who assign both their Medicare and Medigap payments to participants;
- Medicare advertises the participation status in a directory of participating providers to proper demographic groups i.e. senior citizens groups; and
- The supplier has the right to appeal claim determination by the DME MAC contractor on all assigned claims