What is a participating provider?

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The term "participating provider" has different meanings for different provider types.

For physicians and other Part B suppliers, such as suppliers of durable medical equipment, prosthetics, orthotics or supplies (DMEPOS), the term holds the meaning that the supplier of services always will accept assignment on claims submitted on behalf of a Medicare beneficiary. When a supplier accepts assignment, the supplier agrees to bill the beneficiary only for any coinsurance or deductible that may be applicable and accepts the Medicare payment as full payment. Suppliers, generally, have the option of "participating" in this regard. If they choose not to participate, they may still bill Medicare if they are enrolled but may decide on a claim-by-claim basis whether to accept assignment.

Certified providers, such as hospitals and home health agencies, are considered "participating" if they are enrolled in Medicare, and they must follow Medicare rules for billing the program and beneficiaries.

Additional Medicare provider enrollment information and enrollment forms can be found in the Medicare Fee-For-Service Provider/Supplier Enrollment section of www.cms.hhs.gov. Questions regarding provider enrollment can be answered by your local Medicare carrier. The toll-free contact number for your local Medicare Carrier can be found by visiting www.cms.hhs.gov/medlearn/tollnums.asp.


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