Understanding Participating, Nonparticipating and Opt Out Status
| Principles | Participating Status | Nonparticipating Status | Opt Out Status |
|---|---|---|---|
| Explanation | When a physician/practitioner enrolls as a new provider in the Medicare Program, they are given an option to be a participating or a nonparticipating provider. Participating in the Medicare Program means that an enrolled physician/practitioner agrees to accept assignment for all services furnished to Medicare beneficiaries. By accepting assignment, the physician/practitioner agrees to accept the amount approved by Medicare as total payment for covered services, except for the annual deductible and coinsurance. Reimbursement amount, which is 5% higher than the nonparticipating amount, will be paid directly to the provider and Medigap information is transferred. Participating providers will be identified in the MEDPARD and posted to the MAC’s website. |
When a physician/practitioner enrolls as a new provider in the Medicare Program, they are given an option to be a participating or a nonparticipating provider. Nonparticipating in the Medicare Program means an enrolled physician/practitioner is credentialed to submit claims to Medicare. Payments for nonparticipating physician/practitioners are generally sent to the beneficiary. If the physician/practitioner choose to be nonparticipating in the Medicare Program and does not accept assignment on Medicare claims, the maximum amount a beneficiary can be charged is 115% of the approved fee schedule amount for nonparticipating providers. Reimbursement amount, which is 5% less than the participating amount, will be paid to the beneficiary and Medigap information will NOT be transferred. If accept assignment was selected or if mandatory assignment services are submitted on the claim, the reimbursement amount will be 5% less than the participating amount. Clinical laboratory services, drugs and biologicals must be billed as accept assignment. |
When a physician/practitioner opts out, the physician/practitioner and beneficiary cannot submit claims to the Medicare Program. Opt out affidavit filed on or after 6/16/2015, are automatically renewed; therefore, no action is needed unless a physician/practitioner chooses to withdraw the opt out agreement in writing at least 30 days prior to the start of the next opt out period. Note: Opt out affidavit signed before 6/16/2015, will expire two years after the effective date of the opt out period; therefore, if a physician/practitioner choose to extend an opt out, a renewal affidavit must be submitted within 30 days after the current opt out period expires. Note: In rare circumstances, if an opt out physician/practitioner provides emergency or urgent care services, the physician/practitioner may bill Medicare. CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 40.28. (1.22 MB) |
| Physician or Practitioner and Beneficiary Agreement | Inform the beneficiary that the beneficiary is responsible for unmet deductibles, coinsurances and noncovered services. The physician/practitioner would be responsible for submitting claims to Medicare and must accept assignment on all claims. No written notification or private agreement required. Note: Assignment is mandatory on claims for beneficiary(s) dually entitled to both Medicare and Medicaid. Please see Dual Eligible Beneficiaries Under the Medicare and Medicaid Programs. (2.6 MB) |
Inform the beneficiary that the physician/practitioner may bill the beneficiary up-front on a nonassigned basis. The physician/practitioner would be responsible for submitting claims to Medicare, with the option to accept assignment on a claim by claim basis. The beneficiary must be notified in writing of expected financial responsibility, if the provider does not accept assignment on an elective surgery costing more than $500. No written notification or private agreement required. Certain services and/or certain physician/practitioner fall under the mandatory assignment and can be found in the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Sections 30.3.1 through 30.3.12.1. (1.6 MB) Note: Assignment is mandatory on claims for beneficiary(s) dually entitled to both Medicare and Medicaid. Please see Dual Eligible Beneficiaries Under the Medicare and Medicaid Programs. (2.6 MB) |
Inform the beneficiary they must have a signed Medicare Private Agreement with the physician/practitioner. Signing a Medicare Private Agreement called a “Private Contract.” This advises the beneficiary that neither the physician/practitioner, nor the beneficiary can submit claims for Medicare reimbursements. Note: In rare circumstances, if an opt out physician/practitioner provides emergency or urgent care services, the physician/practitioner may bill Medicare.CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 40.28. (1.22 MB) |
| Physician or Practitioner Notification(s) to NGS | During initial enrollment the physician/practitioner will need to complete the CMS-460 form (316 KB) and submit it with the initial enrollment application or within 90 days after initial enrollment. If a physician/practitioner would like to change the participating status after initial enrollment, they may rescind their participation agreement during the annual open enrollment. NGS will mail postcards each year during open enrollment, which is from mid-November through December 31. |
During initial enrollment no action is required if a physician/practitioner does not want to participate with the Medicare Program. If a physician/practitioner did not participate during their initial enrollment, the physician/practitioner will have the opportunity to change their status within the first 90 days of their initial enrollment. If a physician/practitioner would like to change the nonparticipating status after initial enrollment, they may only enroll as participating during the annual open enrollment period. NGS will mail postcards each year during open enrollment, which is from mid-November through December 31. |
Physician/practitioner shall complete and mail the Medicare Opt Out Affidavit notifying NGS that they have a Medicare Private Agreement with beneficiary(s) and are opting out of Medicare Program. The Medicare Opt Out Affidavit shall be sent to NGS no later ten days after entering into the private contract to which the affidavit applies. |
Related Content
- Medicare Participating Physicians Directory (MEDPARD)
- Medicare Participating Physician or Supplier Agreement (CMS-460)
- Omnibus Budget Reconciliation Act of 1986 Section 9332 & 9333
- CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15
- CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 30
- CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 20.4.1
- CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 16, Sections 30.1 & 50.2
- CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 17, Section 50
Reviewed 7/29/2024