Annual Participation Program

CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 30.3.12 outlines an annual open enrollment process, to provide eligible practitioners and suppliers with the opportunity to enroll in or terminate enrollment in the participation program.

For providers (including physicians and suppliers) who have enrolled in Medicare, to sign participation agreement (Form CMS-460) is to agree to accept assignment for all covered services that are provided to Medicare patients. The benefits of signing a participation agreement include:

  • No 5 percent reduction in the Medicare approved amount.
  • Beneficiaries with Medigap coverage (private supplemental insurance) may assign the payment on the supplemental claim to the provider or supplier. Under the current mandatory Medigap (claim-based) crossover process, beneficiaries must assign payment on their claims to a participating provider or supplier as a condition for their claims to be forwarded to their Medigap insurer for payment of all coinsurance and deductible amounts due under the Medigap policy. The Medigap insurer, in turn, must pay the participating provider or supplier directly, thereby relieving the need of having to file a second claim. (Refer to the Medicare Claims Processing Manual, Chapter 28, Section 70.6, for more information regarding the eligibility-file based crossover process.)
  • Listing in the Medicare Participation Physicians/Suppliers Directory (MEDPARD) that is posted on the MAC Web site.
  • Participants receive direct and timely reimbursement from Medicare.

Eligibility

All practitioners and suppliers eligible to receive payments under Part B of Medicare may choose to enter into a participation agreement. This includes practitioners whose services are subject to mandatory assignment. The reason why it could still be appropriate for such practitioners to enter into a participation agreement is because the mandatory assignment provisions apply only to the particular practitioner service benefit (e.g., nurse practitioner services). Thus, for example, if a nurse practitioner is eligible to bill for, and is indeed billing under, Part B for something other than a nurse practitioner service (e.g., an EKG tracing), the mandatory assignment provision of the law does not apply to that other service. However, if the nurse practitioner has entered into a participation agreement, that agreement requires that the nurse practitioner accept assignment for any service for which he or she submits a Medicare Part B claim.

Hold billing until notified of status change. Noridian is unable to submit claims revisions on your behalf for this reason. This open enrollment cycle runs from November 14, 2020 through January 31, 2021.

We encourage you to visit the 2021 Open Enrollment webpage for more information.

 

            Last Updated Thu, 10 Dec 2020 20:41:59 +0000