US · guidance
CMS Pub. 100-16, ch. mc86c18b, § 40.1
Payment for Services Rendered On or After April 1, 1994, by
Noncontracted Medicare Participating Physicians
(Rev. 30, 09-05-03)
The limit of the HCPP's liability for services rendered by a physician with whom it does
not contract depends on whether the physician is a Medicare participating physician (i.e.,
has agreed to accept assignment on all Medicare claims submitted to Medicare). The
Medicare participation agreement is deemed to apply to such a physician's services in the
sense that the physician may not bill the HCPP, the beneficiary, or any other party for any
amount in excess of the Medicare allowed amount (the fee schedule amount or the actual
charge, if lower).
However, the HCPP has financial responsibility for the amount that would have been the
beneficiary's liability in FFS Medicare (the 20 percent coinsurance and any unmet
deductible).
NOTE: The financial responsibility of the HCPP applies only when the services are
covered by the HCPP, i.e., for emergency or urgently needed services or when the HCPP
refers the enrollee to the non-network physician.
History
(Rev. 30, 09-05-03)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
11994f243f9a14e8c7939839918840f7ab07a66b0ab75684e27d98473a5cf704
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