Participating vs Non-participating Supplier - JA DME
Participating vs Non-participating Supplier
National Provider Enrollment (NPE) East Contractor
The National Provider Enrollment (NPE) East is the contractor responsible for issuing or revoking Medicare supplier billing privileges for suppliers of Durable Medical Equipment, Orthotics and Supplies (DMEPOS).
In Medicare, "participation" means you agree to always accept claims assignment for all covered services furnished to Medicare beneficiaries. By agreeing to always accept assignment, you agree to always accept Medicare-allowed amounts as payment in full and not to collect more than the Medicare deductible and coinsurance or copayment from the beneficiary. For claims where assignment is accepted the Medicare payment is sent to the supplier.
The Social Security Act requires suppliers to submit claims for Medicare beneficiaries whether they participate or not. To participate in the Medicare Program as a participating supplier, a Medicare Participating Physician or Supplier Agreement (Form CMS-460) must be completed. Suppliers can submit this form with initial enrollment, or up to 90 days after the enrollment date. The only other time suppliers may change their participation status is during the open enrollment period.
Open enrollment forms, including the CMS-460 and Participation Agreement Form, are mailed to all active suppliers every November. If an existing non-participating supplier wants to become participating, then the agreement form must be received during open enrollment and postmarked before December 31 of that year.
If a participating supplier wants to become non-participating, they can request to become non-participating by sending the request to the NPE on their company letterhead. The request must be postmarked before December 31 of that year to become non-participating effective January 1 of the next year.
Suppliers who choose not to sign the participation agreement are referred to as non-participating suppliers. The non-participating supplier can choose, on a claim-by-claim basis, whether to accept assignment except where CMS regulations require mandatory assignment (e.g., Medicare covered drugs, Indian Health Services, etc.). When a non-participating supplier chooses to bill non-assigned, the Medicare payment is sent directly to the beneficiary. The non-participating supplier may bill the beneficiary no more than the limiting charge for covered services and may collect the payment in full at the time of service.
An assignment agreement is between a supplier of services and a Medicare beneficiary. The option of accepting assignment belongs solely to the supplier.