Medicare Participation Program
Providers enrolled in Part B of the Medicare program and eligible to receive Medicare payments may choose to enter into a Medicare participation agreement by completing a Medicare Participating Physician or Supplier Agreement, Form CMS-460. This form can be downloaded from the Centers for Medicare & Medicaid Services' (CMS) Website at http://www.cms.hhs.gov/cmsforms/cmsforms/list.asp 
The Medicare participation program is optional. It is separate from and in addition to enrollment in the Medicare program.
The legal business entity to which or to whom Medicare benefits are paid makes a single participation decision for the entity. In a group practice setting, for example, the group's participation decision governs all members of the group who have reassigned their Medicare benefits to the group. Similarly, a legal business entity that has multiple practice locations makes a single participation decision for all locations in all states.
The participation agreement applies to items and services for which payment is made on a fee-for-service basis by Medicare Part B carriers. A participation agreement applies to all items and services billed for by the participant (legal business entity), including all names under which the entity does business (DBAs). If the participant opens offices in another carrier jurisdiction during the term of the agreement, the participant must file a photocopy of the agreement with that carrier.
Established providers may enroll in, or terminate their participation in, the program only during Medicare's annual participation enrollment period, normally the last 45 days of the year with changes taking effect the following January 1.
New providers may file a participation agreement with a Medicare carrier at the time of initial enrollment or within 90 days after being enrolled.
Participation agreements filed with the initial CMS 855 enrollment application are effective on the effective date of the Medicare enrollment record. Participation agreements not filed with the initial CMS 855 enrollment application that are filed within 90 days of enrollment are effective on the date of filing, i.e. the date the participant mails the agreement to the carrier (postmark date) or delivers it to the carrier.
Participating Providers
In signing the participation agreement, the provider agrees to accept assignment on all Medicare claims for covered services. Medicare payment on assigned claims is issued directly to the provider; the provider must accept Medicare's approved charge as the provider's full charge for covered services. The provider may bill the beneficiary only for amounts applied to deductible, for the twenty percent coinsurance, and for non-covered charges. Participating providers are not subject to Medicare's limiting charge provision.
Participating providers have "one stop" billing for beneficiaries who have Medigap coverage not connected with their employment and who assign both their Medicare and Medigap payments to the participating provider. After Medicare has processed the claim, it is sent on to the Medigap insurer for payment of coinsurance and deductible amounts due under the Medigap policy, and the Medigap insurer must pay the participating provider directly.
Non-Participating Providers
Non-participating providers have the option of accepting assignment on a claim-by-claim basis. Medicare payment on assigned claims is issued directly to the provider; the provider must accept Medicare's approved charge as the provider's full charge for covered services and may bill the beneficiary only for amounts applied to deductible, for the twenty percent coinsurance, and for non-covered charges. Medicare payment on non-assigned claims is issued to the beneficiary.
Medicare's approved charge for services provided by non-participating providers is 95 percent of the approved charge for a participating provider. Non-assigned claims are subject to Medicare's limiting charge provision. Medicare's limiting charge is 115 percent of Medicare's approved charge. In addition, MinnesotaCare provisions limit charges to Minnesota Medicare beneficiaries to 100 percent of the amount approved by Medicare.
Mandatory Assignment
The following non-physician practitioners are required to accept assignment on all claims for their practitioner services:
- Physician assistants;
- Nurse practitioners;
- Clinical nurse specialists;
- Clinical psychologists;
- Clinical social workers;
- Certified registered nurse anesthetists;
- Certified nurse midwives; and
- Registered dieticians/Nutrition professionals
Mandatory assignment does not apply to non-practitioner services, such as the technical component of diagnostic tests. Non-physician practitioners therefore may choose whether or not to be participating providers for such services--subject to the participation decision of the legal business entity billing for the services.
Providers in Wisconsin, Illinois, and Michigan may direct questions regarding Medicare's participation program to Wisconsin Physicians' Service's (WPS) Provider Enrollment Department at (877) 908-8476. Providers in Minnesota may call WPS' Provider Enrollment Department at (866)-564-0315.
