Participating Status on Provider Enrollment Approval Letters

If the Medicare Participating Physician or Supplier Agreement (CMS-460) is not submitted during initial enrollment or during the annual participation open enrollment period, the individual provider or group would be considered to have an active enrollment with Medicare but reflect a nonparticipating status.

If a physician or nonphysician practitioner has employment arrangements or reassigns benefits to a group/individual, their rendering individual provider claims for that group/individual would be paid according to the participating status of the group/individual, not the participating status reflected on the individual approval letter.

Any approval letter addressing an individual provider would reflect the individual provider’s participation status currently established and only claims submitted as a sole proprietor would reflect that participating status.

An approval letter addressing a group would reflect the group’s participation status currently established and all claims submitted would reflect the participating status of the group.

Note: CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 10.6.11: Nonphysician practitioners that are considered mandatory participation and individual physicians and nonphysician practitioners that reassign all of their benefits to a participating organization should not be entered as participating in PECOS, which will state nonparticipation on the approval letter.

Reviewed 7/27/2024