CMS Pub. 100-04, ch. 1, § 30.3.1.1

Suppliers

(Rev. 3510, Issued: 04-29-16, Effective: 10-01-16, Implementation; 10-03-16)

The participating physician or supplier submits any claims for services furnished by the

physician or supplier, except in the limited circumstances specified in §30.2.8.3 or

§30.2.16. (The exception concerns situations where the physician or supplier accepts, as

full payment, payment by certain organizations.) When an unassigned claim is received

from a physician, the A/B MAC (B) must verify that the physician is participating. The

contractor processes the claim as assigned absent clear evidence of intent by the

physician or beneficiary not to assign.

Any Form CMS-1500 claim where the participating physician or supplier checks either

the assignment or non-assignment block or fails to check either block, the A/B MAC (B)

must treat it as assigned.

Where there is evidence of clear intent not to assign, the A/B MAC (B) must deny the

claim. Use MSN 16.6.

“This item or service cannot be paid unless the provider accepts

assignment.

In Spanish:

“Este artículo o servicio no se pagará a menos de que el proveedor acepte

asignación.”

A/B MAC (B) must identify and track assignment violations in the event sanctions must

be imposed.

No Part B payment is made on a claim by a participating physician or supplier to anyone

other than the physician or supplier (except in the case of court-ordered assignment to

other parties under §30.2) even if the beneficiary has paid part of the bill. However, if

the physician or supplier collects any charges from the beneficiary before submitting the

claim, he/she must show on the claim form the amount collected. The carrier refunds

directly to the beneficiary, to the extent feasible, any over collection of deductible and

coinsurance. The physician is responsible for refunding to the beneficiary any over

collection not refunded by the carrier directly. In these latter instances, the carrier

advises the physician of his/her obligation to refund any over collections to the

beneficiary. Also, the carrier advises the beneficiary of the amount of any refund due

from the physician.