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Participating Provider Facts

  • Although providers may enroll in the Medicare program or change an enrollment status at anytime, there are only two instances in which providers may enroll in or terminate enrollment from the participation program. One is within 90 days of initial enrollment into the Medicare program. The other is during the annual open enrollment period.
  • Accepting assignment means that the service provider has made a "participating agreement" with Medicare to accept the "allowable charge" determined by Medicare as full payment for that service. However, Medicare generally pays 80 percent of the "allowable charge." The beneficiary is still liable to the provider for the 20 percent coinsurance. In addition to the coinsurance, the beneficiary is responsible for paying the annual Part B deductible and for paying any non-covered services.
  • A participating provider receives a Medicare provider number to bill Medicare for services rendered. To determine whether or not your services are covered under the Medicare Participating Agreement, you must know the status of the Medicare provider number used to bill your services. Physicians, clinics, groups, non-physicians, and other health care professionals can have provider numbers.
  • Most clinics or groups of physicians are listed only under the clinic or group name. In these cases, you need to know whether or not the clinic or group has a provider number. All physicians in a clinic must agree to participate before the clinic can hold a provider number.
  • Some physicians practice in more than one clinic. In this case, one clinic may hold a Medicare providing number while the second may not. Before services are provided, be sure to check with the office you expect to visit to ensure your services will be covered.
  • A physician may hold a Medicare provider number under his/her individual name but also practice in a clinic or group. If you receive services at the clinic or group, you should ensure that the clinic or group also holds a Medicare provider number.
  • The MEDPARDExternal Websitecontains the addresses provided by the physicians and suppliers. We have tried to verify this information is accurate. However, we recommend that you call to verify the participant's information and provider number before making an appointment.
  • The scheduled participating provider enrollment period is held each year in the fall. At that time, physicians can choose to enter or leave the program. Shortly after the enrollment period, a revised MEDPARDExternal Websitewill be issued.
  • A detailed explanation of how to locate a Medicare participating provider is contained in the MEDPARDExternal Website.

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