non participating provider medicare, Non-Participating Providers

Billing Guidelines For Medicare Non-Participating Providers (2022)

Non-participating providers can bill Medicare as well. Part B of Medicare-covered services has to be billed to Medicare.

Providers who fail to bill these services can face penalties because of the so-called “Mandatory Claim Submission Rule.”

According to CMS, the only exception, in this case, is if the beneficiary signed a valid Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, with Option #2 selected.

1. What Is a Non-Participating Provider?

A non-participating provider is enrolled as a Medicare provider but receives payment in a different way than participating Medicare providers.

Non-participating providers still have to bill Medicare because the beneficiary can still be reimbursed if Medicare is responsible for part of the claim.

Non-participating providers typicaly get paid directly from their Medicare patients.

2. Can A Non-Participating Provider Accept Assignments?

Yes, a non-participating provider can accept assignments. According to CMS, the beneficiary payment needs to be reported with Item 29 of the CMS 1500 claim form to ensure that the beneficiary is reimbursed before the provider is paid.

Non-participating providers receive 5% less reimbursement than participating providers, according to the annual Medicare Physician Fee Schedule.

3. Where Can I Find A Medicare Participating Provider Agreement?

The Medicare Participating Provider Agreement covers information about the participation process of medicare providers.

You can find a copy of the Medicare Participating Provider Agreement on the website of CMS.

4. Claims Reviews For Non-Participating Providers

Any Medicare claim submitted can be audited/reviewed; the physician’s participation status does not affect the possibility of this occurring. Therefore, as a non-participating provider, you must audit or review claims.

CMS reviews/audits aim to protect Medicare trust funds. It also identifies billing errors. This helps coders to avoid the mistakes in the future.


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