CMS Pub. 100-04, ch. 1, § 30.3.12

For providers (including physicians and suppliers) who have enrolled in Medicare, to

sign a participation agreement (Form CMS-460) is to agree to accept assignment for all

covered services that are provided to Medicare patients. The benefits of signing a

participation agreement include:

• No 5 percent reduction in the Medicare approved amount.

• Beneficiaries with Medigap coverage (private supplemental insurance) may

assign the payment on the supplemental claim to the provider or supplier. Under

the current mandatory Medigap (claim-based) crossover process, beneficiaries

must assign payment on their claims to a participating provider or supplier as a

condition for their claims to be forwarded to their Medigap insurer for payment

of all coinsurance and deductible amounts due under the Medigap policy. The

Medigap insurer, in turn, must pay the participating provider or supplier directly,

thereby relieving the need of having to file a second claim. (Refer to the

Medicare Claims Processing Manual, Chapter 28, Section 70.6, for more

information regarding the eligibility-file based crossover process.)

• Listing in the Medicare Participation Physicians/Suppliers Directory

(MEDPARD) that is posted on the carrier Web site.

• Participants receive direct and timely reimbursement from Medicare.

Refer to §30.3.1 for processing instructions for claims for practitioner services

inadvertently submitted as unassigned.

A Eligibility

All practitioners and suppliers eligible to receive payments under Part B of Medicare may

choose to enter into a participation agreement. This includes practitioners whose services

are subject to mandatory assignment. The reason why it could still be appropriate for

such practitioners to enter into a participation agreement is because the mandatory

assignment provisions apply only to the particular practitioner service benefit (e.g., nurse

practitioner services). Thus, for example, if a nurse practitioner is eligible to bill for, and

is indeed billing under, Part B for something other than a nurse practitioner service (e.g.,

an EKG tracing), the mandatory assignment provision of the law does not apply to that

other service. However, if the nurse practitioner has entered into a participation

agreement, that agreement requires that the nurse practitioner accept assignment for any

service for which he or she submits a Medicare Part B claim.

B Participation Enrollment Period

Carriers conduct an enrollment period on an annual basis in order to provide eligible

practitioners and suppliers with the opportunity to enroll in or terminate enrollment in the

participation program. They are given specific instructions each year regarding the dates

during which the enrollment period is in effect.

C Circumstances in Which A Participating Physician or Supplier is Not Required

to Accept Assignment for Covered Services

A participating physician or supplier is not required to accept assignment for covered

services when an entity (other than the beneficiary), which is eligible to request direct

payment from the Medicare program for the services, pays the physician or supplier and

the physician or supplier accepts that payment as full payment.

For example, a private supplementary health benefits plan may pay the physician or

supplier an amount, which the physician or supplier accepts as payment in full and then

collect the Part B payment directly from the Medicare program. This procedure, called

indirect payment or payment to organizations, permits a physician or supplier to submit a

single claim for the Medicare and private plan benefits to the private health benefits plan.

The physician or supplier may accept plan payment in excess of the Medicare approved

charge.

The availability of this procedure depends on the extent to which health benefit plans are

eligible and choose to use it. The indirect payment procedure is also available to

nonparticipating physicians or suppliers.

D Entities Eligible to Enter Into Agreement to Be Participating Physicians or

Suppliers

Any person or organization that is authorized to accept assignment of Medicare benefits

for covered services may enter into a participating physician agreement. This includes

(but is not limited to):

• Practitioners such as physicians, podiatrists, dentists, optometrists, and

chiropractors;

• Hospitals, medical groups, and other entities which are authorized to bill and to

receive payment for physician services;

• Organizations such as group practice prepayment plans, prepaid health plans,

HMOs, and competitive medical plans which submit claims to Medicare carriers;

and

• Suppliers such as independent physical therapists, medical equipment supply

companies, independent laboratories, ambulance services, and portable X-ray

suppliers.

E Applicable Rules When Physicians Work for a Hospital or Medical Group

The following rules apply when physicians work for (or are members of) a hospital,

medical group, or other entity:

• Except in the case of university medical centers, if a hospital, medical group, or

other entity bills and receives payment for physician services in the name of the

entity (rather than have the individual physicians bill and receive payment in

their own names), one participation agreement by the entity binds all physicians

with respect to any services furnished for the entity. The individual physicians

do not enter into participation agreements.

NOTE: In university medical centers, when individual departments bill

under the name and provider identification number of the department,

decisions for or against participation can be made on a departmental basis.

• If a physician who is associated with a particular entity has an individual practice

outside the scope of the practice for which the entity bills and receives payment,

he or she may choose whether to participate with respect to his/her outside

practice without regard to the participation status of the entity.

• If individual physicians who work for an entity bill and receive payment in their

own names for the services furnished for the entity, they make individual

decisions as to whether to participate. These decisions apply both to the

physicians’ services for the entity and to any outside practice.

F Services Subject to Agreement

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 participating agreement applies to

all items and services in all localities and under all names and identification numbers

under which the participant does business.

The participant lists all names and identification numbers under which the participant

submits claims to the carrier. This includes all names and numbers of the legal entity

entering into the agreement, whether that entity is a sole proprietorship, partnership, or

corporation.

If the participant opens offices in another carrier jurisdiction during the term of the

agreement, he or she must file a photocopy of the agreement with that carrier.

G Acknowledgment of Receipt

Carriers acknowledge receipt of an agreement by sending the physician or supplier a

photocopy of the agreement, which has been annotated with the effective date.

H Where to File Agreement

An agreement is valid if it is filed with any Medicare carrier in a timely manner.

A new participant must file an original agreement with the carrier in their region and a

photocopy of the agreement by a date that CMS specifies on an annual basis with any

other carriers which have assigned the participant a physician identification number and

to which the participant submits claims. When submitting a photocopy of the agreement

to a carrier, the new participant must identify in the letter transmitting the photocopy all

names and identification numbers under which the participant submits claims to that

carrier and indicate the name of the carrier to which the original agreement was mailed or

delivered and the date it was mailed or delivered.

If the new participant enters into a valid agreement but does not also timely file a

photocopy of the agreement with another carrier with which the participant does

business, it may be too late for the participant to be listed in that carrier’s directory of

participating physicians. Nevertheless, the agreement is still binding, and it is important

for the physician or supplier to submit a photocopy of the agreement to that carrier, even

if late, because of advantages of the agreement, which are still available with late filing.

It is not necessary for the new participant to file a photocopy of the agreement with

Palmetto GBA, the carrier for Railroad Retirement Board beneficiaries. The new

participant’s carrier will furnish Palmetto GBA with participating physician/suppler data

(see Section 30.3.12.1.J. of this chapter).

Note that for DMEPOS suppliers, the NSC handles the participation agreements.

I Duration of Agreement

An agreement entered into, or continuing in effect, for a given year remains in effect

through that year and may not be revoked during that period.

The agreement is renewed automatically for each 12-month period thereafter unless,

during the enrollment period provided near the end of the 12-month period, the

participant gives proper written notice of a wish to terminate the agreement at the end of

its current term. Proper written notice means written notice to all carriers with whom the

participant has filed the agreement or a copy of the agreement.

The CMS may terminate the agreement if it finds, after notice and opportunity for

hearing, that the participant has substantially failed to comply with the agreement. There

are also civil and criminal penalties, identical to those for assignment violations, which

may be imposed for violation of the agreement.

Note that for DMEPOS suppliers, the NSC handles the participation agreements.

J When New Physician or Supplier in Area May Enter Into Agreement

A physician/supplier who has enrolled in the Medicare program and wishes to become a

participating physician/supplier must file an agreement with a Medicare carrier within 90

days after either of the following events:

• The participant is newly licensed to practice medicine or another health care

profession; or

• The participant first opens offices for professional practice or other health care

business in a particular carrier service area or locality (regardless of whether the

participant previously had or retains offices elsewhere).

If a physician has an arrangement with a hospital, medical group, or other entity under

which the entity bills in its name for his/her services, changes that arrangement and then

begins to bill in his/her own name, he/she is considered to be first opening offices, even

though he/she practices in the same location.

The participating enrollment package is included with the CMS-855 form for new

enrollees. Carriers must furnish a special participating agreement form for new

physicians or suppliers upon request or at the time you assign the new physician or

supplier an identification number.

When the agreement is filed on one of the above bases, it is effective on the date of filing,

i.e., the date the participant mails (postmark date) the agreement to the carrier or delivers

it to the carrier. The initial period of the agreement may be less than 12 months.

Otherwise, the terms of the agreement are the same as those of an agreement entered into

by other physicians or suppliers. The agreement applies to all services in all localities.

The physician or supplier must submit the original agreement to the carrier in their region

and photocopies to all carriers with whom he or she deals.

If a physician or supplier first enters into an agreement after publication of your

directory, his or her name is not included in the directory until subsequent publication.

This may not occur until the next annual publication date. Carriers must make the names

of those physicians or suppliers entering into agreements after the initial deadline

available on the toll free telephone lines as each physician or supplier enters into an

agreement.

Note that for DMEPOS suppliers, the NSC handles the participation agreements.