accept assignment meaning

As a Medical Biller, the better you understand the medical insurance payment process, the better you can care for your patients. Your understanding of what a patient will owe and what will be covered can help them navigate the confusing world of medical insurance.

One term that can be very confusing for patients (and for doctors as well) is ‘Accepting Assignment’.

Essentially, ‘assignment’ means that a doctor, (also known as provider or supplier) agrees (or is required by law) to accept a Medicare-approved amount as full payment for covered services.

This amount may be lower or higher than an individual’s insurance amount, but will be on par with Medicare fees for the services.

If a doctor participates with an insurance carrier, they have a contract and agree that the provider will accept the allowed amount, then the provider would check “yes”.  

If they do not participate and do not wish to accept what the insurance carrier allows, they would check “no”.   It is important to note that a provider who does not participate can still opt to accept assignment on just a particular claim by checking the “yes” box just for those services.

In other words by saying your office will accept assignment, you are agreeing to the payment amount being covered by the insurer, or medicare, and the patient has no responsibility.

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Does your provider accept Medicare as full payment?

You can get the lowest cost if your doctor or other health care provider accepts the Medicare-approved amount  as full payment for a covered service. This is called “accepting assignment.” If a provider accepts assignment, it’s for all Medicare-covered Part A and Part B services.

Using a provider that accepts assignment

Most doctors, providers, and suppliers accept assignment, but always check to make sure that yours do.

If your doctor, provider, or supplier accepts assignment:

• Your out-of-pocket costs may be less.
• They agree to charge you only the Medicare deductible and coinsurance amount, and usually wait for Medicare to pay its share before asking you to pay your share.
• They have to submit your claim directly to Medicare and can't charge you for submitting the claim.

How does assignment impact my drug coverage?

Using a provider that doesn't accept Medicare as full payment

Some providers who don’t accept assignment still choose to accept the Medicare-approved amount for services on a case-by-case basis. These providers are called "non-participating."

If your doctor, provider, or supplier doesn't accept assignment:

• You might have to pay the full amount at the time of service.
• They should submit a claim to Medicare for any Medicare-covered services they give you, and they can’t charge you for submitting a claim. If they refuse to submit a Medicare claim, you can submit your own claim to Medicare. Get the Medicare claim form .
• They can charge up to 15% over the Medicare-approved amount for a service, but no more than that. This is called "the limiting charge."  

Does the limiting charge apply to all Medicare-covered services?

Using a provider that "opts-out" of Medicare

• Doctors and other providers who don’t want to work with the Medicare program may "opt out" of Medicare.
• Medicare won’t pay for items or services you get from provider that opts out, except in emergencies.
• Providers opt out for a minimum of 2 years. Every 2 years, the provider can choose to keep their opt-out status, accept Medicare-approved amounts on a case-by-case basis ("non-participating"), or accept assignment.

Find providers that opted out of Medicare.

Private contracts with doctors or providers who opt out

• If you choose to get services from an opt-out doctor or provider you may need to pay upfront, or set up a payment plan with the provider through a private contract.
• Medicare won’t pay for any service you get from this doctor, even if it’s a Medicare-covered service.

What are the rules for private contracts?

You may want to contact your  State Health Insurance Assistance Program (SHIP) for help before signing a private contract with any doctor or other health care provider.

What do you want to do next?

• Next step: Get help with costs
• Take action: Find a provider
• Get details: How to get Medicare services

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What is Medicare assignment and how does it work?

Kimberly Lankford,

​Because Medicare decides how much to pay providers for covered services, if the provider agrees to the Medicare-approved amount, even if it is less than they usually charge, they’re accepting assignment.

A doctor who accepts assignment agrees to charge you no more than the amount Medicare has approved for that service. By comparison, a doctor who participates in Medicare but doesn’t accept assignment can potentially charge you up to 15 percent more than the Medicare-approved amount.

That’s why it’s important to ask if a provider accepts assignment before you receive care, even if they accept Medicare patients. If a doctor doesn’t accept assignment, you will pay more for that physician’s services compared with one who does.

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How much do I pay if my doctor accepts assignment?

If your doctor accepts assignment, you will usually pay 20 percent of the Medicare-approved amount for the service, called coinsurance, after you’ve paid the annual deductible. Because Medicare Part B covers doctor and outpatient services, your $240 deductible for Part B in 2024 applies before most coverage begins.

All providers who accept assignment must submit claims directly to Medicare, which pays 80 percent of the approved cost for the service and will bill you the remaining 20 percent. You can get some preventive services and screenings, such as mammograms and colonoscopies , without paying a deductible or coinsurance if the provider accepts assignment. 

What if my doctor doesn’t accept assignment?

A doctor who takes Medicare but doesn’t accept assignment can still treat Medicare patients but won’t always accept the Medicare-approved amount as payment in full.

This means they can charge you up to a maximum of 15 percent more than Medicare pays for the service you receive, called “balance billing.” In this case, you’re responsible for the additional charge, plus the regular 20 percent coinsurance, as your share of the cost.

How to cover the extra cost? If you have a Medicare supplement policy , better known as Medigap, it may cover the extra 15 percent, called Medicare Part B excess charges.

All Medigap policies cover Part B’s 20 percent coinsurance in full or in part. The F and G policies cover the 15 percent excess charges from doctors who don’t accept assignment, but Plan F is no longer available to new enrollees, only those eligible for Medicare before Jan. 1, 2020, even if they haven’t enrolled in Medicare yet. However, anyone who is enrolled in original Medicare can apply for Plan G.

Remember that Medigap policies only cover excess charges for doctors who accept Medicare but don’t accept assignment, and they won’t cover costs for doctors who opt out of Medicare entirely.

Good to know. A few states limit the amount of excess fees a doctor can charge Medicare patients. For example, Massachusetts and Ohio prohibit balance billing, requiring doctors who accept Medicare to take the Medicare-approved amount. New York limits excess charges to 5 percent over the Medicare-approved amount for most services, rather than 15 percent.

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How do I find doctors who accept assignment?

Before you start working with a new doctor, ask whether he or she accepts assignment. About 98 percent of providers billing Medicare are participating providers, which means they accept assignment on all Medicare claims, according to KFF.

You can get help finding doctors and other providers in your area who accept assignment by zip code using Medicare’s Physician Compare tool .

Those who accept assignment have this note under the name: “Charges the Medicare-approved amount (so you pay less out of pocket).” However, not all doctors who accept assignment are accepting new Medicare patients.

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What does it mean if a doctor opts out of Medicare?

Doctors who opt out of Medicare can’t bill Medicare for services you receive. They also aren’t bound by Medicare’s limitations on charges.

In this case, you enter into a private contract with the provider and agree to pay the full bill. Be aware that neither Medicare nor your Medigap plan will reimburse you for these charges.

In 2023, only 1 percent of physicians who aren’t pediatricians opted out of the Medicare program, according to KFF. The percentage is larger for some specialties — 7.7 percent of psychiatrists and 4.2 percent of plastic and reconstructive surgeons have opted out of Medicare.

Keep in mind

These rules apply to original Medicare. Other factors determine costs if you choose to get coverage through a private Medicare Advantage plan . Most Medicare Advantage plans have provider networks, and they may charge more or not cover services from out-of-network providers.

Before choosing a Medicare Advantage plan, find out whether your chosen doctor or provider is covered and identify how much you’ll pay. You can use the Medicare Plan Finder to compare the Medicare Advantage plans and their out-of-pocket costs in your area.

Return to Medicare Q&A main page

Kimberly Lankford is a contributing writer who covers Medicare and personal finance. She wrote about insurance, Medicare, retirement and taxes for more than 20 years at  Kiplinger’s Personal Finance  and has written for  The Washington Post  and  Boston Globe . She received the personal finance Best in Business award from the Society of American Business Editors and Writers and the New York State Society of CPAs’ excellence in financial journalism award for her guide to Medicare.

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Find-A-Code Articles, Published 2014, August 1

What does accept assignment mean.

by   InstaCode Institute Aug 1st, 2014 - Reviewed/Updated Mar 5th

What does it mean to accept assignment on the CMS 1500 claim form - also called the HCFA 1500 claim form.? Should I accept assignment or not? What are the guidelines for accepting assignment in box 27 of the 1500 claim?

These commonly asked questions should have a simple answer, but the number of court cases indicates that it is not as clear cut as it should be. This issue is documented in the book “Problems in Health Care Law” by Robert Desle Miller. The definition appears to be in the hands of the courts. However, we do have some helpful guidelines for you.

One major area of confusion is the relationship between box 12, box 13 and box 27.  These are not interchangeable boxes and they are not necessarily related to each other.

According to the National Uniform Claim Committee (NUCC), the "Accept Assignment" box indicates that the provider agrees to accept assignment.  It simply says to enter an X in the correct box.  It does NOT define what accepting assignment might or might not mean.

It is important to understand that if you are a participating provider in any insurance plan or program, you must first follow the rules according to the contract that you sign. That contract supersedes any guidelines that are included here.

Medicare Instructions / Guidelines

PARTICIPATING providers MUST accept assignment according to the terms of their contract.  The contract itself states:

“Meaning of  Assignment  - For purposes of this agreement, accepting  assignment  of the Medicare Part B payment means requesting direct Part B payment from the Medicare program.  Under an  assignment , the approved charge, determined by the Medicare carrier, shall be the full charge for the service covered under Part B.  The participant shall not collect from the beneficiary or other person or organization for covered services more than the applicable deductible and coinsurance.”

By law, the providers or types of services listed below MUST also accept assignment:

• Clinical diagnostic laboratory services;
• Physician services to individuals dually entitled to Medicare and Medicaid;
• Services of physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives, certified registered nurse anesthetists, clinical psychologists, and clinical social workers;
• Ambulatory surgical center services for covered ASC procedures;
• Home dialysis supplies and equipment paid under Method II;
• Ambulance services;
• Drugs and biologicals; and
• Simplified Billing Roster for influenza virus vaccine and pneumococcal vaccine.

NON-PARTICIPATING providers can choose whether to accept assignment or not, unless they or the service they are providing is on the list above.

The official Medicare instructions regarding Boxes 12 and 13 are:

“Item 12 – The patient's signature authorizes release of medical information necessary to process the claim. It  also authorizes payments of benefits  to the provider of service or supplier when the provider of service or supplier accepts assignment on the claim.” “Item 13 - The patient’s signature or the statement “signature on file” in this item  authorizes payment of medical benefits  to the physician or supplier. The patient or his/her authorized representative signs this item or the signature must be on file separately with the provider as an authorization. However, note that when payment under the Act can only be made on an assignment-related basis or when payment is for services furnished by a participating physician or supplier, a patient’s signature or a “signature on file” is not required in order for Medicare payment to be made directly to the physician or supplier.”

Regardless of the wording on these instructions stating that it authorizes payments to the physician, this is not enough to ensure that payment will come directly to you instead of the patient.To guarantee payment comes to you, you MUST accept assignment.

Under Medicare rules, PARTICIPATING providers are paid at 80% of the  physician fee schedule allowed amount  and NON-participating providers are paid at 80% of the allowed amount, which is 5% less than the full Allowed amount for participating providers. Only NON-participating providers may "balance bill" the patient for any amounts not paid by Medicare, however, they are subject to any state laws regarding balance billing.

TIP: If you select YES, you may or may not be subject to a lower fee schedule, but at least you know the payment is  supposed  to come to you.

NON-MEDICARE Instructions / Guidelines

PARTICIPATING providers MUST abide by the terms of their contract.  In most cases, this includes the requirement to accept assignment on submitted claims.

NON-PARTICIPATING providers have the choice to accept or not accept assignment.

YES means that payment should go directly to you instead of the patient.  Generally speaking, even if you have an assignment of benefits from the patient (see box 12 & 13), payment is ONLY guaranteed to go to you IF you accept assignment.

NO is appropriate for patients who have paid for their services in full so they may be reimbursed by their insurance.  It generally means payment will go to the patient.

What Does Accept Assignment Mean?. (2014, August 1). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/what-does-accept-assignment-mean-34840.html

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What to Know About How Medicare Pays Physicians

Alex Cottrill , Juliette Cubanski , and Tricia Neuman Published: Mar 06, 2024

More than 65 million people— nearly 20% of the U.S. population —receive their health insurance coverage through the federal Medicare program. In 2021, Medicare spending comprised one-fifth (21%) of national health care spending and 13% of the federal budget . The largest share of total Medicare spending ( 48% in 2021 ) is dedicated to Part B services, including physician services, outpatient services, and physician-administered drugs, and accounts for 26% of national payments for physician and clinical services.

Each year, the Centers for Medicare and Medicaid Services (CMS) updates Medicare payments to physicians and other clinicians through rulemaking, based on parameters established under law. In November 2023, CMS finalized a 3.4% decrease in the physician fee schedule conversion factor, a key aspect of payment rates under the Medicare program, resulting in a 1.25% decrease in overall payments that is expected to vary by specialty . These changes, along with several others, went into effect on January 1, 2024 (Figure 1). Congress is expected to vote on legislation that would mitigate these payment reductions temporarily, from March 9, 2024 through the remainder of the year.

Figure 1: Timeline of Major Provisions Impacting the Medicare Physician Fee Schedule

Physician and other professional groups, including the American Medical Association, the Medical Group Management Association, and the American Hospital Association, have opposed the payment cuts and expressed concerns that loss of revenue could push physicians to opt out of the Medicare program, leading to access problems for Medicare beneficiaries. Physicians are not required to take Medicare patients, but most do; just 1% opted out of the program in 2023.

The new legislation that adjusts physician payments through the remainder of the year is one of several recent proposals from policymakers aimed at canceling out or mitigating these payment reductions. Since 2020, Congress has enacted four temporary, one-year increases to physician payment rates to avoid reductions in fees. Others, including MedPAC , have proposed broader changes to address concerns with the current payment system. A bipartisan group of senators recently announced the formation of a Medicare payment reform working group, with the goal of investigating long-term reforms to the physician fee schedule, and additional legislation is expected later in the year.

This issue brief answers key questions about how physicians are paid under the Medicare program, and reviews policy options under discussion for payment reform. The brief is focused primarily on the physician payment system used in traditional Medicare, as Medicare Advantage plans have flexibility to pay providers differently; currently there is no information on how much Medicare Advantage plans pay providers. (See Appendix for a glossary of relevant programs, legislation, and terms.)

1. What is the Medicare physician fee schedule?

Medicare reimburses physicians and other clinicians based on the physician fee schedule , which assigns payment rates for more than 10,000 health care services , such as office visits, diagnostic procedures, or surgical procedures. For services provided to traditional Medicare beneficiaries, Medicare typically pays the provider 80% of the fee schedule amount, with the beneficiary responsible for a maximum of 20% in coinsurance. Physicians who participate in Medicare agree to accept this arrangement as payment in full (known as accepting “assignment”) for all Medicare covered services. Others, known as non-participating physicians, may accept “assignment” on a claim-by-claim basis and may choose to bill for larger amounts by charging additional coinsurance, up to a limit. Physicians who opt out of the program altogether enter into private contracts with their Medicare patients, are not limited to charging fee schedule amounts, and do not receive any reimbursement from Medicare.

Fee schedule rates for a given service are based on a weighted sum of three components: clinician work, practice expenses, and professional liability insurance (also known as medical malpractice insurance), measured in terms of relative value units (RVUs). Together these three components represent the overall cost and effort associated with a given service, with more costly or time-intensive services receiving a higher weighted sum. Each component is adjusted to account for geographic differences in input costs, and the result is multiplied by the fee schedule conversion factor (an annually adjusted scaling factor that converts numerical RVUs into payment amounts in dollars).

Payment rates specified under the physician fee schedule establish a baseline amount that Medicare will pay for a given service, but payments may be adjusted based on other factors, such as the site of service, the type of clinician providing the service, and whether the service was provided in a designated health professional shortage area . Physicians can also receive quality-based payment adjustments under the Quality Payment Program (QPP) (see question 6).

2. How does Medicare update physician payment rates?

Annual updates to the physician fee schedule include statutorily-required updates to the conversion factor under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (see question 5), as well as other adjustments to reflect the addition of new services, changes in input costs for existing services, and other factors. A multispecialty committee of physicians and other professionals, known as the AMA/Specialty Society RVS Update Committee (RUC) , issues annual recommendations to advise CMS on the weighting of new or revised service codes.

Under current law, the projected cost of all changes to the physician fee schedule must be budget neutral, that is, the changes may not raise total Medicare spending by more than $20 million in a given year. This requirement was established by the Omnibus Budget Reconciliation Act of 1989 to address concerns that constraints on physician fees for specific services would lead to increases in service volume, potentially driving growth in Medicare spending for physician services over time. The law requires CMS to adjust fee schedule spending when projected costs exceed the threshold, typically by decreasing the conversion factor relative to the statutory update called for by MACRA.

3. How have physician payment rates changed in 2024?

CMS recently finalized payment changes for 2024, including increases in payment for a range of services related to primary care, behavioral health, and direct patient care, among others (see question 4). Due to the statutory requirement under the Omnibus Budget Reconciliation Act of 1989 that CMS preserve budget neutrality when adjusting physician payment rates, these service-specific increases necessitated a decrease to the fee schedule conversion factor to offset additional costs. Budget neutrality adjustments are made separately from statutory adjustments under MACRA and any temporary payments provided by Congress, both of which may also impact the conversion factor in a given year.

The 3.4% decrease to the conversion factor finalized for 2024 reflects the following adjustments to these three factors: (1) a -2.18% budget neutrality adjustment, (2) a 0% statutory increase under MACRA for 2024, and (3) -1.25% reduction in temporary payments provided by Congress for 2024 under the Consolidated Appropriations Act of 2023 .

The combined impact of these changes is a -1.25% decrease in overall payments under the physician fee schedule relative to 2023, according to CMS. Payment changes are expected to vary by specialty , however. For example, clinicians most directly impacted by service-specific changes, such as those in primary care and behavioral health, are projected to see a net increase in payments, while clinicians in radiology, physical and occupational therapy, and some surgical specialties are projected to see the largest net decrease.

Congress is expected to vote on pending legislation which would mitigate the 3.4% decrease to the fee schedule conversion factor, a change which is expected to result in a modest increase to physician payment rates across all specialties, relative to current law.

4. What other changes have been finalized by CMS for 2024?

Many of the provisions in the physician fee schedule final rule for 2024 are part of a wider effort by CMS and the Department of Health and Human Services (HHS) to improve health equity and increase support for primary care services, addressing long-standing concerns about the gap in compensation between primary and specialty care physicians (see question 7). CMS has also implemented two provisions of the Consolidated Appropriations Act of 2023 , which expand Medicare coverage for a range of behavioral health services. The final payment rule for 2024 includes the following key changes:

• CMS has added new billing codes to the physician fee schedule, allowing clinicians to bill separately for time dedicated to care coordination and direct patient care services, such as caregiver training, assessment of health-related social needs, and coordination with community health workers, care navigators, and peer support specialists.
• CMS has added a new add-on payment that allows clinicians to bill at higher rates for evaluation and management visits deemed to be complex, such as visits that are central to coordinating all of a patient’s needed health services or part of treatment for a serious, ongoing health condition.
• CMS has added new billing codes related to psychotherapy for crisis services, and existing codes can be billed by a broader range of providers. Additionally, new types of behavioral health providers, such as mental health counselors (MHCs) and marriage and family therapists (MFTs) can now bill for reimbursement under the physician fee schedule, following legislation passed under the Consolidated Appropriations Act of 2023 .
• CMS has extended several telehealth flexibilities that were granted on a temporary basis during the COVID-19 pandemic through the end of 2024, including provisions that allow Medicare beneficiaries to receive telehealth services from any site, including their home, delay the requirement for an in-person visit within six months of initiating mental or behavioral telehealth services, and allow telehealth services to be offered by Rural Health Clinics and Federally Qualified Health Centers .
• CMS has added health and well-being coaching to the Medicare Telehealth Services list through the end of 2024, and Social Determinants of Health Risk Assessments have been added on a permanent basis. Finally, CMS has expanded the definition of covered telehealth practitioners to include qualified occupational therapists, physical therapists, speech-language pathologists, and audiologists.

The new rules also include updates to the Medicare Shared Savings Program (MSSP) , as well as other changes related to payment for opioid treatment programs, preventive vaccine administration, and a variety of other health services.

5. How have Medicare payments to physicians evolved over time?

Medicare has revised its system of payment for physician services numerous times over the years (Figure 1). The current payment system was established under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) , which included a schedule for annual, statutorily-defined updates to the conversion factor, a key determinant of payment rates under the physician fee schedule. These updates are set by legislation and do not vary based on underlying economic conditions. However, further adjustments to preserve budget neutrality and supplemental payments provided by Congress may result in conversion factor updates that are higher or lower than the statutory update in a given year.

The physician payment framework established by MACRA was intended to stabilize fluctuations in payment caused by the prior payment system under the Medicare Sustainable Growth Rate (SGR) formula , which set annual targets for Medicare physician spending based on growth in the gross domestic product (GDP). Under the SGR, if spending exceeded its target in a given year, payment rates would be cut the following year, while spending that was below the target led to increased rates. As with the current system, rates were subject to further adjustment for budget neutrality if the projected cost of all fee schedule spending increased by more than $20 million for the year.

The SGR was established by the Balanced Budget Act of 1997 to slow the growth in Medicare spending for physician services, but the formula garnered criticism , as growth in service volume and rising costs led to several years of spending that exceeded the growth target, necessitating payment cuts from 2002 onward. Between 2002 and 2015, Congress enacted 17 short-term interventions (so-called “doc-fixes”) to delay the cuts and provide temporary increases to physician payments, but did so without repealing the SGR, which resulted in accumulated deficits over time.

MACRA permanently eliminated the SGR formula, preventing a 21.2% cut in physician fees slated for 2015 and replacing it with 0% statutory increases to the conversion factor through 2025 (later raised to 0.5% from 2016-2019), followed by modest annual increases from 2026 onward. While overall payments were not scheduled to increase for the first decade of MACRA’s operation, the legislation also included new pathways to allow for payment increases through bonus payments and quality-based payment adjustments under the Quality Payment Program (QPP) (see question 6).

Although MACRA has stabilized payments under the physician fee schedule to some degree, rates have continued to fluctuate over the last decade. Since 2020, Congress has provided four temporary, one-year increases to fee schedule rates to boost payment during the COVID-19 pandemic and offset prior budget-neutrality cuts, raising concerns that the cycle of “doc-fixes” under the SGR formula has not been wholly fixed (see question 7).

6. How does the QPP factor into physician payments?

The Quality Payment Program (QPP) was established by MACRA in 2015 to create financial incentives for health care providers to control costs and improve care quality. Under the QPP, physicians and other clinicians who participate in qualified advanced alternative payment models (A-APMs) , such as select accountable care organizations (ACOs) and others , are eligible for bonus payments if they meet certain participation thresholds. A-APMs are a type of value-based care model in which the provider bears some financial risk for the costs of care, typically by sharing in a portion of financial savings and losses relative to a benchmark. Qualifying A-APM clinicians receive an annual 5% bonus through 2024, which will be lowered to 3.5% in 2025, and replaced with an annual 0.75% increase to the conversion factor beginning in 2026 (relative to a 0.25% increase for all other clinicians). Roughly 240,000 clinicians received this bonus in 2022, based on participation during the 2020 payment year.

Clinicians who do not participate in A-APMs, or do not meet the participation criteria for A-APM bonus payments, are subject to additional reporting requirements under the Merit-based Incentive Payment System (MIPS) , which adjusts payments up or down depending on a clinician’s performance on certain quality metrics. Clinicians are required to participate in MIPS if they are eligible, but many are exempt , such as those in certain specialties (e.g., podiatrists), those in their first year of Medicare participation, and those who serve a low volume of Medicare patients. Roughly half of all Medicare Part B providers (49%) were eligible for MIPS in 2019.

Payment adjustments under MIPS are capped each year ( between +9% and -9% in 2022 ), and savings generated from clinicians who incur negative adjustments are used to fund positive adjustments for those who qualify. Because a relatively small share of clinicians have incurred negative adjustments each year since MIPS was implemented, positive adjustments have generally been much lower than the annual cap. In 2022, roughly 850,000 clinicians received positive adjustments up to 1.87%, while just 19,000 clinicians received negative adjustments down to -9%.

7. What concerns have been raised about the current payment system?

Criticism of the recent payment cuts under the physician fee schedule has focused on three primary concerns about the way in which Medicare pays physicians and other clinicians. These include: (1) the overall adequacy of Medicare payments to cover medical practice costs and incentivize participation in the Medicare program, (2) the gap in compensation between primary and specialty care clinicians, and (3) the success of the QPP at achieving its goal of incentivizing quality improvements and cost-efficient spending.

Payment Adequacy: Physician groups and others have expressed concern that certain aspects of the current payment system, such as the requirement for budget neutrality under the physician fee schedule and the limited flexibility of conversion factor updates under MACRA, have resulted in payment rates that are too low to keep up with inflation in medical practice costs. Practice expenses are one component of the relative-value calculation used to determine payment rates for fee schedule services, but the need to preserve budget neutrality makes it difficult for CMS to increase payment for some services without also decreasing payment in other areas, such as by lowering the fee schedule conversion factor.

Physician groups and others have pointed out that statutory increases to the conversion factor under MACRA are not scheduled to begin until 2026, and do not vary based on underlying economic conditions. Further, a prior KFF review of the literature has shown that Medicare pays less for physician services , on average, than private insurers, leading physician groups and some policymakers to warn about potential access issues for beneficiaries that could result if physicians are driven to opt out of the Medicare program in the future due to payment rates.

However, access problems for beneficiaries have generally not materialized to date. According to MedPAC, Medicare beneficiaries report access to clinician services that is equal to, or better than , that of privately insured individuals. A recent KFF analysis found that just 1% of all non-pediatric physicians had opted out of the Medicare program in 2023, suggesting that the current fee structure has not substantially discouraged participation. Moreover, MedPAC estimates that virtually all Medicare claims (99.7% in 2021) are accepted on “assignment” and paid at the standard rate, with beneficiaries in traditional Medicare facing no more than the standard 20% coinsurance rate.

Primary Care Compensation: A second concern with the current payment system is that Medicare does not adequately pay for primary care services, as reflected by the gap in Medicare payments between primary and specialty care clinicians. Payments under the physician fee schedule are generally higher for procedures (e.g., surgeries) than non-procedural services (e.g., evaluation and management). MedPAC has expressed concern that this imbalance encourages clinicians to focus on more costly and profitable services at the expense of high-value, but less profitable, services, such as patient education, preventive care, and coordination across care teams, which leads to higher physician spending over time.

Role of the QPP: QPP programs such as MIPS and bonus payments for A-APM clinicians are designed to create incentives for quality improvements, care coordination, and high-value services. While the share of clinicians who qualify for A-APM bonuses has increased substantially since the QPP began (from roughly 99,000 in 2017 to 271,000 in 2021), some policymakers have argued that greater incentives are needed to encourage providers to take on the financial risks and high startup costs associated with these models. Additionally, MedPAC has expressed concern that MIPS, the quality-based payment program for clinicians who do not participate in A-APMs, does not give providers enough incentives to improve quality and control costs. As noted earlier, a large share of clinicians are exempt from the program, and because few participants receive negative adjustments, positive adjustments are relatively modest .

8. What policy proposals have been put forward to address concerns with the current physician payment system?

In addition to legislation that directly addresses the 2024 payment cuts, policymakers and others have put forward a number of strategies to revise the current physician payment system. These include measures to prevent fluctuations in payment from year to year, provide additional support to primary care and safety-net providers, and create stronger incentives for efficient spending, care coordination, and participation in A-APMs.

Several bills have been introduced in Congress that would raise or modify the budget neutrality threshold, allowing CMS greater flexibility to adjust payment rates to reflect evolving policy priorities without necessitating a mandatory payment cut. For example, legislation has been introduced that would provide regular updates to the budget neutrality threshold based on growth in the Medicare Economic Index (MEI), a measure of inflation in the prices of goods and services used by clinicians to provide care. Further, a bipartisan coalition of physicians in Congress recently introduced the Strengthening Medicare for Patients and Providers Act , which would tie annual updates to the fee schedule’s conversion factor to the annual percentage increase in the MEI.

In 2023, MedPAC also recommended a one-time inflation-based increase to physician payment rates in 2024 (equal to 50% of the projected increase in the MEI), but has not recommended annual updates for inflation, focusing instead on targeted strategies to bolster payments to primary care clinicians and safety-net providers. Their recommendations include a permanent add-on payment for services provided to low-income Medicare beneficiaries, raising payment in these instances by 15% for claims billed by primary care clinicians and 5% for claims billed by non-primary care clinicians.

MedPAC has voiced support for the goals behind MACRA and the QPP, including the financial incentives offered to A-APM participants under current law. At the same time, MedPAC has recommended significant changes to the design of the QPP, including the elimination of MIPS, based on concerns that it does not give providers enough incentives to make significant practice improvements. In its place, MedPAC has recommended a voluntary program designed to mimic the structure of A-APMs and other alternative payment models , allowing clinicians to transition into these models more gradually. Finally, some policymakers have introduced legislation that would extend bonus payments for qualifying A-APM clinicians though the end of 2026.

In addition to these more targeted proposals, a bipartisan group of senators recently announced the formation of a Medicare payment reform working group, which will investigate long-term reforms to the physician fee schedule and updates to the physician payment legislation provided by MACRA.

Not yet 10 years out from the passage of MACRA, these measures suggest growing interest in Medicare physician payment reform, beyond addressing the physician fee cuts finalized for 2024. Designing payment approaches that address concerns raised by interested parties to compensate physicians adequately while restraining spending growth represents a challenge for policymakers.

This work was supported in part by Arnold Ventures. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.

• Health Costs
• Federal Budget
• Access to Care

Also of Interest

• How Many Physicians Have Opted Out of the Medicare Program?
• Recent Changes to Medicare Coverage of Dental Services from the 2023 and 2024 Medicare Physician Fee Schedule Final Rules
• 10 Things to Know About Medicaid Managed Care

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If you have Original Medicare , your Part B costs once you have met your deductible can vary depending on the type of provider you see. For cost purposes, there are three types of provider, meaning three different relationships a provider can have with Medicare . A provider’s type determines how much you will pay for Part B -covered services.

• These providers are required to submit a bill (file a claim ) to Medicare for care you receive. Medicare will process the bill and pay your provider directly for your care. If your provider does not file a claim for your care, there are troubleshooting steps to help resolve the problem .
• If you see a participating provider , you are responsible for paying a 20% coinsurance for Medicare-covered services.
• Certain providers, such as clinical social workers and physician assistants, must always take assignment if they accept Medicare.
• Non-participating providers can charge up to 15% more than Medicare’s approved amount for the cost of services you receive (known as the limiting charge ). This means you are responsible for up to 35% (20% coinsurance + 15% limiting charge) of Medicare’s approved amount for covered services.
• Some states may restrict the limiting charge when you see non-participating providers. For example, New York State’s limiting charge is set at 5%, instead of 15%, for most services. For more information, contact your State Health Insurance Assistance Program (SHIP) .
• If you pay the full cost of your care up front, your provider should still submit a bill to Medicare. Afterward, you should receive from Medicare a Medicare Summary Notice (MSN) and reimbursement for 80% of the Medicare-approved amount .
• The limiting charge rules do not apply to durable medical equipment (DME) suppliers . Be sure to learn about the different rules that apply when receiving services from a DME supplier .
• Medicare will not pay for care you receive from an opt-out provider (except in emergencies). You are responsible for the entire cost of your care.
• The provider must give you a private contract describing their charges and confirming that you understand you are responsible for the full cost of your care and that Medicare will not reimburse you.
• Opt-out providers do not bill Medicare for services you receive.
• Many psychiatrists opt out of Medicare.

Providers who take assignment should submit a bill to a Medicare Administrative Contractor (MAC) within one calendar year of the date you received care. If your provider misses the filing deadline, they cannot bill Medicare for the care they provided to you. However, they can still charge you a 20% coinsurance and any applicable deductible amount.

Be sure to ask your provider if they are participating, non-participating, or opt-out. You can also check by using Medicare’s Physician Compare tool .

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What Does It Mean for a Doctor to Accept Medicare Assignment?

Written by: Malini Ghoshal, RPh, MS

Reviewed by: Malinda Cannon, Licensed Insurance Agent

Key Takeaways

Doctors who accept Medicare assignment are paid agreed-upon rates for services.

It’s important to verify that your doctor accepts assignment before receiving services to avoid high out-of-pocket costs.

A doctor or clinician may be “non-participating” but can still agree to accept Medicare assignment for some services.

If you visit a doctor or clinician who has opted out (doesn’t accept Medicare), you may have to pay for your entire visit cost unless it’s a medical emergency.

Medigap Supplemental insurance (Medigap) plans won’t pay for service costs from doctors who don’t accept assignment.

One of the things that Original Medicare beneficiaries often enjoy about their coverage is that they can use it anywhere in the country. Unlike plans with provider networks, they can visit doctors either at home or on the road; both are covered the same.

But do all doctors accept Medicare patients?

Truth is, this wide-ranging coverage area only applies to doctors who accept Medicare assignment. Fortunately, most do. If you’re eligible for Medicare, it’s important to visit doctors and clinicians who accept Medicare assignment. This will help keep your out-of-pocket costs within your control. Doctors who agree to accept Medicare assignment sign an agreement that they’re willing to accept payment from Medicare for their services.

If you’re a current beneficiary or nearing enrollment, you may have other questions. Do all doctors accept Medicare Advantage plans? What about Medicare Supplement insurance (Medigap)? Read on to learn how to find doctors that accept Medicare assignment and how this keeps your healthcare costs down.

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What Is Medicare Assignment of Benefits?

When you’re eligible for Medicare, you have the option to visit doctors and clinicians who accept assignment. This means they are Medicare-approved providers who agree to receive Medicare reimbursement rates for covered services. This helps save you money.

If you have Original Medicare (Part A and B), your doctor visits are covered by your Part B plan. Inpatient services such as hospital stays and some skilled nursing care are covered by Part A .

In order for a participating doctor (or facility) to bill Medicare and be reimbursed, you must authorize Medicare to reimburse your doctor directly for your covered services. This is called the Medicare assignment of benefits. You transfer your right to receive Medicare payment for a covered service to your doctor or other provider.

Note: If you have a Medicare Supplement insurance ( Medigap ) plan to pay for out-of-pocket costs, you may also need to sign a separate assignment of benefits form for Medigap reimbursement. More on Medigap below.

How Can I Find Doctors Near Me That Accept Medicare?

There are several ways to find doctors and other clinicians who accept Medicare assignment close to you.

First, let’s take a look at the different types of Medicare providers.

They include:

Participating providers: Medicare-participating doctors and providers sign a participation agreement stating they will accept Medicare reimbursement rates for their services.

Non-participating providers:  Doctors or providers who are non-participating providers are eligible to accept Medicare assignment but haven’t signed a Medicare agreement. They may choose to accept assignment on a case-by-case basis. If you visit a non-participating provider, make sure to ask if they accept assignment for your particular service. Also get a copy of their fees. They will need to select “yes” on Centers for Medicare & Medicaid Services CMS Form 1500 to accept assignment for the service.

Opt-out providers:  Some doctors and other providers choose not to accept Medicare. If they choose to opt out, the period is two years (based on Medicare guidelines). The opt-out automatically renews if the provider doesn’t request a change in their status. You would be responsible for paying all costs for services received from an opt-out provider. You cannot bill Medicare for reimbursement unless the service was an urgent or emergency medical need. According to a report from KFF , roughly 1% of non-pediatric physicians opted out of Medicare in 2023.

Visiting a doctor who doesn’t accept assignment may cost you more. These providers can charge you up to 15% more than the Medicare-approved rate for a given service. This 15% charge is called the limiting charge. Some states limit this extra charge to a certain percent. This may also be called the Part B excess charge.

Here are some tips for finding doctors and providers who accept Medicare assignment:

• The easiest way to find a doctor who accepts Medicare assignment is to contact their office and ask them directly.
• If you’re looking for a new doctor, you can use the Medicare search tool to find clinicians and doctors that accept Medicare assignment.
• You can also ask a state health insurance assistance program (SHIP) representative for help in locating a doctor that accepts Medicare assignment.
• Don’t assume that having a longstanding relationship with your doctor means nothing will ever change. Check in with them to make sure they still accept Medicare assignment and whether they’re planning to opt out.

Note: Your doctor can choose to become a non-participating provider or opt out of participating in Medicare. It’s important to verify they accept Medicare assignment before receiving any services.

Find the Medicare Plan that works for you.

Do Doctors Who Accept Medicare Have to Accept Supplement Plans?

If your doctor accepts Medicare assignment and you have Original Medicare (Medicare Part A and Part B) with a Medicare Supplement (Medigap) plan, they will accept the supplemental insurance. Depending on your Medigap plan coverage , it may pay all or part of your out-of-pocket costs such as deductibles, copayments and coinsurance.

However, if you have a Medicare Advantage plan (Part C), you may have a network of covered doctors under the plan. If you visit an out-of-network doctor, you may need to pay all or part of the cost for your services.

Keep in mind that you can’t have a Medigap supplemental plan if you have a Medicare Advantage plan.

If you have questions or want to learn more about different Medicare plans like Original Medicare with Medigap versus Medicare Advantage, GoHealth has licensed insurance agents ready to help. They can shop your different options and offer impartial guidance where you need it.

Do Most Doctors Accept Medicare Advantage Plans?

Many doctors accept Medicare Advantage (Part C) plans, but these plans often use provider networks. These networks are groups of doctors and providers in an area that have agreed to treat an insurance company’s customers. If you have a Part C plan, you may be required to see in-network doctors with few exceptions. However, these types of plans are popular options for all-in-one coverage for your health needs. Plans must offer Part A and B coverage, plus a majority also include Part D , or prescription drug coverage. But whether a doctor accepts a Medicare Advantage plan may depend on where you live and the type of Medicare Advantage plan you have.

There are several types of Medicare Advantage plans including:

• Health Maintenance Organization (HMO): These plans have a network of covered providers, as well as a primary care physician to manage your care. If you visit a doctor outside your plan network, you may have to pay the full cost of your visit.
• Preferred Provider Organization (PPO): You’ll probably still have a primary care physician, but these are more flexible plans that allow you to go out of network in some cases. But you may have to pay more.
• Private Fee for Service (PFFS): You may be able to visit any doctor or provider with these plans, but your costs may be higher.
• Special Needs Plan (SNP): This type of plan is only for certain qualified individuals who either have a specific health condition ( C-SNP ) or who qualify for both Medicaid and Medicare insurance ( D-SNP ).

Find a local Medicare plan that fits your needs.

What Are Medicare Assignment Codes?

Medicare assignment codes help Medicare pay for covered services. If your doctor or other provider accepts assignment and is a participating provider, they will file for reimbursement for services with a CMS-1500 form and the code will be “assigned.”

But non-participating providers can select “not assigned.” This means they are not accepting Medicare-assigned rates for a given service. They can charge up to 15% over the full Medicare rate for the service.

If you go to a doctor or provider who accepts assignment, you don’t need to file your own claim. Your doctor’s office will directly file with Medicare. Always check to make sure your doctor accepts assignment to avoid excess charges from your visit.

Health Insurance Claim Form . CMS.gov.

Lower costs with assignment . Medicare.gov.

How Many Physicians Have Opted-Out of the Medicare Program? KFF.org.

Joining a plan . Medicare.gov.

This website is operated by GoHealth, LLC., a licensed health insurance company. The website and its contents are for informational and educational purposes; helping people understand Medicare in a simple way. The purpose of this website is the solicitation of insurance. Contact will be made by a licensed insurance agent/producer or insurance company. Medicare Supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program. Our mission is to help every American get better health insurance and save money. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.

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What does ‘accepting assignment’ mean?

Accepting assignment is a real concern for those who have Original Medicare coverage. Physicians (or any other healthcare providers or facilities) who accept assignment agree to take Medicare’s payment for services. They cannot bill a Medicare beneficiary in excess of the Medicare allowance, which is the copayment or coinsurance. While providers who participate in the Medicare program must accept assignment on all Medicare claims, they do not have to accept every Medicare beneficiary as a patient. 

There are basically three Medicare options for physicians.

• Physicians may sign a participating agreement and accept Medicare’s allowed charge as payment-in-full for all of their Medicare patients. Use the Physician Compare database to find physicians who accept assignment. 
• They may elect to be non-participating, in which case, they make decisions about accepting Medicare assignment on a case-by-case basis. They can bill patients up to 15% more than the Medicare allowance. Some Medigap policies offer a benefit to cover this amount, known as Part B excess charges.
• Or, they may opt out of Medicare entirely and become private contracting physicians.  They establish contracts with their patients to bill them directly. Neither the physicians nor the patients would receive any payments from Medicare.

Accepting assignment can also be a concern for beneficiaries with coverage other than Original Medicare, including those:

• in a Medicare Advantage Private Fee-for-service (PFFS) plan who get services outside the network.
• in a Medicare Advantage Medical Savings Account (MSA) plan because this plan does not utilize networks.

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Medicare Provider Enrollment Print

What’s Changed?

• Updated the enrollment application fee amount for 2024
• Added marriage and family therapists, mental health counselors, and certain dental specialties to the Part B suppliers list
• Merged Form CMS-855R into the CMS-855I paper enrollment application
• Added new provider specialty code information for dentists

Substantive content changes are in dark red.

Application Fee

Physicians, non-physician practitioners, physician organizations, non-physician organizations, and Medicare Diabetes Prevention Program suppliers don’t pay a Medicare enrollment application fee.

Generally, institutional providers and suppliers like DMEPOS suppliers and opioid treatment programs pay an application fee when enrolling, re-enrolling, revalidating, or adding a new practice location.

Enrollment Application Fee

The 2024 enrollment application fee is $709.

Whether you apply for Medicare enrollment online or use the paper application, you can pay the Medicare application fee online through:

• PECOS: During the application process, PECOS prompts you to pay the application fee
• CMS Paper Application: Go to PECOS Application Fee Information to submit the application fee

A hardship exception exempts you from paying a current application’s fee. If you request a hardship exception, submit a written request and supporting documentation describing the hardship and justifying an exception to paying the application fee with your PECOS or CMS paper application. We grant exceptions on a case-by-case basis.

Medicare Administrative Contractors (MACs) will only process applications with the proper application fee payment or an approved hardship exception.

If you don’t pay the fee or submit a hardship exception request, your MAC will send a letter allowing you 30 days to pay the fee. If you don’t pay the fee on time, the MAC may reject or deny your application or revoke your existing billing privileges, as appropriate.

Providers must enroll in the Medicare Program to get paid for providing covered services to Medicare patients. Determine if you’re eligible to enroll and how to complete enrollment.

We list institutional providers on the Medicare Enrollment Application: Institutional Providers (CMS-855A) , which include:

• Community mental health centers
• Comprehensive outpatient rehabilitation facilities
• Critical access hospitals
• ESRD facilities
• Federally Qualified Health Centers
• Histocompatibility labs
• Home health agencies
• Hospice organizations
• Indian Health Service facilities
• Organ procurement organizations
• Opioid treatment programs
• Outpatient physical therapy, occupational therapy, speech pathology services
• Religious nonmedical health care institutions
• Rural emergency hospitals
• Rural health clinics
• Skilled nursing facilities (SNFs)

Physicians, non-physician practitioners (NPPs), clinics or group practices, and specific suppliers who can enroll as Medicare Part B providers are defined in enrollment forms Medicare Enrollment Application: Physicians and Non-Physician Practitioners (CMS-855I) and Medicare Enrollment Application: Clinics/Group Practices and Other Suppliers (CMS-855B) .

Who’s an NPP?

NPPs include nurse practitioners, clinical nurse specialists, and physician assistants who practice with or under a physician’s supervision.

Physicians, NPPs, & Suppliers (CMS-855I)

• Anesthesiology assistants
• Audiologists
• Certified nurse-midwives
• Certified registered nurse anesthetists
• Clinical nurse specialists
• Clinical psychologists
• Clinical social workers
• Marriage and family therapists
• Mass immunization roster billers (individuals)
• Mental health counselors
• Nurse practitioners
• Occupational or physical therapists in private practice
• Dental anesthesiology
• Dental public health
• Endodontics
• Oral and maxillofacial surgery
• Oral and maxillofacial pathology
• Oral and maxillofacial radiology
• Oral medicine
• Orofacial pain
• Orthodontics and dentofacial orthopedics
• Pediatric dentistry
• Periodontics
• Prosthodontics
• Physician assistants
• Psychologists billing independently
• Registered dietitians or nutrition professionals
• Speech-language pathologists

Clinics, Group Practices, & Specific Suppliers (CMS-855B)

• Ambulatory surgical centers (ASCs)
• Clinics and group practices
• Home infusion therapy suppliers
• Hospital departments
• Independent clinical labs
• Independent diagnostic testing facilities
• Intensive cardiac rehabilitation suppliers
• Mammography centers
• Mass immunization roster billers (entities)
• Physical or occupational therapy groups in private practice
• Portable X-ray suppliers
• Radiation therapy centers

Medicare Diabetes Prevention Program Suppliers

Potential suppliers must use Medicare Enrollment Application: Medicare Diabetes Prevention Program (MDPP) Suppliers (CMS-20134) to enroll in the Medicare Program.

Beginning January 1, 2024, we established new provider specialty codes for dentists.

If you don’t see your provider type listed, contact your MAC’s provider enrollment center before submitting a Medicare enrollment application.

Medicare provider and supplier organizations have business structures, like corporations, partnerships, professional associations, or limited liability companies, which meet the provider and supplier definitions. Provider and supplier organizations don’t include organizations the IRS defines as sole proprietorships.

Provider and supplier organizations include:

• Medical group practices and clinics

You must have a provider or supplier employer identification number (EIN) to enroll in Medicare. An EIN is the same as the provider or supplier organization’s IRS-issued tax identification number (TIN).

Sole Proprietorships & Disregarded Entities

Sections 10.6.4 and 10.6.7.1(D)(5) of Medicare Program Integrity Manual, Chapter 10 have more information about sole proprietorships and disregarded entities.

Medicare participation means you agree to accept claims assignment for all covered patient services. By accepting assignment, you agree to accept Medicare-allowed amounts as payment in full. You can’t collect more from the patient than the deductible and coinsurance or copayment . The Social Security Act says you must submit patient Medicare claims whether or not you participate.

You have 90 days after we send your initial enrollment approval letter to decide if you want to be a participating provider or supplier. To participate as a Medicare Program provider or supplier, submit the Medicare Participating Physician or Supplier Agreement (CMS-460) upon initial enrollment. The only other time you may change your participation status is during the open enrollment period, generally from mid-November–December 31 each year.

Participating Provider or Supplier

• We pay 5% more to participating physicians and other suppliers
• Because these are assigned claims, we pay you directly
• We forward claim information to Medigap (Medicare supplement coverage) insurers

Non-Participating Provider or Supplier

• We pay 5% less to non-participating physicians and other suppliers
• You can’t charge patients more than the limiting charge, 115% of the Medicare Physician Fee Schedule amount
• You may accept assignment on a case-by-case basis
• You have limited appeal rights

Medicare Claims Processing Manual, Chapter 12 has more information.

Step 1: Get an NPI

To enroll in the Medicare Program, get an NPI through:

• Online Application: Get an Identity & Access Management (I&A) System user account. Then apply for an NPI in NPPES .
• Call 1-800-465-3203 (TTY 1-800-692-2326)
• Email [email protected]
• Bulk Enumeration: Apply for Electronic File Interchange access and upload your own CSV or XML files.

Not Sure If You Have an NPI?

Search for your NPI on the NPPES NPI Registry .

CMS Provider Enrollment Systems:

• I&A System
• Electronic Health Record (EHR) Incentive Payments

Multi-Factor Authentication

To better protect your information, we implemented I&A System multi-factor authentication for the provider enrollment systems listed above.

Step 2: Complete Proper Medicare Enrollment Application

After you get an NPI, you can complete Medicare Program enrollment, revalidate your enrollment, or change your enrollment information. Before applying, get the necessary enrollment information , and complete the actions using PECOS or the paper enrollment form.

A. Online PECOS Application

After we approve your I&A System registration, submit your PECOS application.

PECOS offers a scenario-driven application, asking questions to recover the information for your specific enrollment scenario. You can use PECOS to submit all supporting documentation. Follow these instructions:

• Log in to PECOS .
• Continue with an existing enrollment or create a new application.
• When PECOS determines your enrollment scenario and you confirm it’s correct, you’ll see the topics for submitting your application. To complete each topic, enter the necessary information.
• Confirms you entered all necessary data
• Lists MAC documents to submit for review
• Gives the option to electronically sign and certify
• Shows your MAC’s name and mailing address
• Lets you print your enrollment application for your records (don’t submit a paper copy to your MAC)
• Sends the application electronically to your MAC
• Emails you to confirm your MAC got the application

PECOS 2.0 Enhancements

PECOS will have enhanced features to better meet your needs. Watch this 2-minute video or read these FAQs to learn more about:

• A single application for multiple enrollments
• Data pre-population and an application that’s tailored to you
• Enhanced capability to add or delete group members
• Real-time processing checks and status updates
• Revalidation reminders

Visit Introducing PECOS 2.0 for more information.

PECOS Scroll Functionality

PECOS validates that you’ve read and acknowledged certification terms and conditions before you electronically submit your Medicare enrollment application. Review and scroll through each text box with certification requirements before you can select accept on these pages:

• Remote E-sign

Enrolling physicians, NPPs, or other Part B suppliers must choose 1 of the application descriptions below.

• You’re the only owner of a business, set up as a corporation, where you provide health care services
• Your business is legally separate from your personal assets
• You provide all health care services from a facility you own, lease, or rent
• You’re the only owner of a business that provides health care services
• You and your business are legally 1 and the same
• You’re personally responsible for the business’ financial obligations, and you report business income and losses on your personal tax return
• You provide all health care services as an employee of a group practice or clinic
• You arrange with your employer to submit claims and get paid for your services
• Choose Group Member Only if you’re reassigning all your benefits to a group practice or clinic
• You provide health care services as a group practice or clinic employee
• You agree with your employer to submit claims and get paid for your services
• You also provide health care services from a facility that you own, lease, or rent
• Your income through self-employment is part of your personal assets
• Your corporation doesn’t file taxes; instead, you file corporate taxes on your personal tax filing

B. Paper Medicare Enrollment Applications

Submit the appropriate paper enrollment application if you’re unable to use PECOS. Carefully review the paper application instructions to decide which form is right for your practice. The paper enrollment application collects your information, including documentation verifying your Medicare Program enrollment eligibility.

If you submit a paper application, your MAC processes your application and creates a Medicare enrollment record by entering the data into PECOS.

Medicare Enrollment Application: Institutional Providers (CMS-855A) : Institutional providers use this form to begin the Medicare enrollment or revalidation process or to change enrollment information.

Most physicians and NPPs complete the CMS-855I to begin the enrollment process. You can also use the CMS-855I if you reassign your benefits to another entity, like a medical group or group practice that gets paid for your services. We’ve merged the CMS-855R into the CMS-855I paper enrollment application.

• Medicare Enrollment Application: Clinics/Group Practices and Other Suppliers (CMS-855B) : Group practices and other organizational suppliers, except DMEPOS suppliers, use this form to begin the Medicare enrollment or revalidation process or to change enrollment information.
• Medicare Enrollment Application: Enrollment for Eligible Ordering/Certifying Physicians and Other Eligible Professionals (CMS-855O) : Physicians and other eligible NPPs use this form to enroll in Medicare solely to order or certify items or services for Medicare patients. This includes those physicians and other eligible NPPs who don’t send billed services claims to a MAC.
• Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers (CMS-855S) : DMEPOS suppliers use this form to begin the Medicare enrollment or revalidation process or to change enrollment information.
• Medicare Enrollment Application: Medicare Diabetes Prevention Program (MDPP) Suppliers (CMS-20134) : MDPP suppliers use this form to begin the Medicare enrollment or revalidation process or to change enrollment information.

After you submit an enrollment application and all required supporting documentation to your MAC, they’ll send their recommendations to the State Survey Agency . The State Survey Agency then decides if specific providers meet Medicare enrollment conditions.

After a MAC makes a recommendation, the State Survey Agency or a CMS-recognized accrediting organization conducts a survey. Based on the survey results, the agency or organization recommends that we approve or deny the enrollment (certification of compliance or non-compliance).

Certain institutional provider types may elect voluntary accreditation by a CMS-recognized accrediting organization instead of a State Survey Agency. The accrediting organization will notify the State Survey Agency of their decision.

The State Survey Agency forwards us the survey results. We assign the CMS Certification Number and effective date, sign the provider agreement, and update the certification database. Your MAC will issue your final approval or denial letter.

If approved, you’ll get a fully executed provider agreement.

Electronic Funds Transfer

If enrolling in Medicare, revalidating, or making certain changes to your enrollment, we require you to set up an electronic funds transfer (EFT). Enroll in EFT by completing the PECOS EFT information section. When submitting a PECOS application:

• Complete the EFT information for your organization (if appropriate) or yourself
• Include a copy of a voided check or bank letter that has your individual or business legal name and applicable account and routing numbers

Step 3: Respond to Requests for More Information

MACs pre-screen and verify enrollment applications for completeness. If the MAC needs more information, respond to information requests within 30 days. If you don’t, the MAC may reject your enrollment .

Your MAC won’t fully process your PECOS enrollment application without your electronic or uploaded signature, application fee (if applicable), and necessary supporting documentation. The enrollment application filing date is when the MAC gets your enrollment application.

You can check your PECOS enrollment application status 2 ways:

• Log in to PECOS and select the View Enrollments link. In the Existing Enrollments section, find the application. The system shows the application status.
• To see your enrollment status without logging in, go to PECOS and, under Helpful Links , select Application Status.

When your MAC approves your application, it switches the PECOS record to an approved status and sends you an approval letter.

Provider Enrollment Site Visits

We conduct a site visit verification process using National Site Visit Contractors (NSVCs). A site visit helps prevent questionable providers and suppliers from enrolling or staying enrolled in the Medicare Program.

The NSVCs conduct unannounced site visits for all Medicare Part A and B providers and suppliers, including DMEPOS suppliers. The NSVCs may conduct an observational site visit or a detailed review to verify enrollment-related information and collect other details based on pre-defined CMS checklists and procedures.

During an observational visit, the inspector has minimal contact with the provider or supplier and doesn’t hinder the facility’s daily activities. The inspector will take facility photos as part of the site visit. During a detailed review, the inspector enters the facility, speaks with staff, and collects information to confirm the provider’s or supplier’s compliance with our standards.

Inspectors performing site visits will carry a photo ID and a CMS-issued, signed authorization letter the provider or supplier may review. If the provider or its staff want to verify we ordered a site visit, contact your MAC .

Make your office staff aware of the site visit verification process. An inspector’s inability to perform a site visit may result in denial of your Medicare enrollment application or revocation of your Medicare billing privileges.

Step 4: Use PECOS to Keep Enrollment Information Current

Report a Medicare enrollment change using PECOS. Physicians, NPPs, and physician and NPP organizations must report a change of ownership or control (including a change in authorized or delegated official), a change in practice location, and any final adverse legal actions (like a felony or suspension of a federal or state license) within 30 days of the change and report all other changes within 90 days of the change.

DMEPOS suppliers must report changes in their enrollment application information within 30 days of the change.

Independent diagnostic testing facilities must report changes in ownership, location, general supervision, and adverse legal actions within 30 days of the change and report all other changes within 90 days of the change.

Medicare Diabetes Prevention Program suppliers must report changes in ownership, including AO or Access Manager; location; coach roster; and adverse legal actions within 30 days of the change and report all other changes within 90 days of the change.

PECOS Users

We allow various organizations and users to work in our systems. The type of user depends on their relationship with you and the duties they perform in your practice.

You may choose other users to act for your organization to manage connections and staff, including appointing and approving other system-authorized users. Depending on your professional relationships with other providers, the CMS External User Services Help Desk may ask you for additional validation information.

One Account, Multiple Systems

We use several provider enrollment systems. Organizational providers and suppliers must use the Identity & Access Management (I&A) System to name an AO to work in CMS systems. The I&A System allows you to:

• Use NPPES to apply for and manage NPIs
• Use PECOS to enroll in Medicare or update or revalidate your current enrollment information
• Register to get electronic health record (EHR) incentive payments for eligible professionals and hospitals that adopt, use and upgrade, or show meaningful use of EHR technology

Authorized Officials, Access Managers, Staff End Users, & Surrogates

Organizational providers or suppliers must appoint and authenticate an Authorized Official (AO) through the I&A System to work in PECOS for them. That person must meet the AO regulatory definition. For example, an AO is a chief executive officer, chief financial officer, general partner, chair of the board, or direct owner who can legally enroll in the Medicare Program.

Respond to your employer’s AO invitation or initiate the request yourself. After you’re the confirmed AO, use PECOS for your provider or supplier organization. As an AO, you’re responsible for approving PECOS user system requests to work on behalf of the provider or supplier organization. Regularly check your email and take the requested actions.

AOs may delegate their responsibilities to an Access Manager who can also initiate or accept connections and manage staff for their organizations.

AOs or Access Managers may invite a Staff End User (SEU) or Surrogate to access PECOS for their organization. Once registered, an SEU or Surrogate may log in to access, view, and modify CMS system information, but they can’t represent the practice, manage staff, sign enrollment applications, or initiate or accept connections.

We recommend using the same I&A System-appointed AO and PECOS Access Managers. The assigned AO and Access Managers must have the right to legally bind the company and be responsible for approving the system staff and be CMS-approved in the I&A System.

Only AOs can sign an initial organization enrollment application. An Access Manager can sign changes, updates, and revalidations.

The I&A System Quick Reference Guide has detailed instructions on managing system users.

PECOS Technical Help

Using PECOS may require technical support. The first step toward a solution is knowing which CMS contractor to contact.

Common Problems & Who to Contact

You experience system-generated error messages, have trouble navigating through or accessing PECOS screens, encounter printing problems, or your valid I&A System user ID and password won’t allow PECOS access because of a malfunction (for example, the website operates slowly or not at all or a system-generated error message prevents you from entering data).

A system-generated error message doesn’t include messages created when you enter data incorrectly or ignore system prompts.

Solution: Contact the CMS External User Services Help Desk

The External User Services website has information on common problems and allows you to ask questions, chat live with a support team member, or look up previous support history.

Phone: 1-866-484-8049 (TTY 1-866-523-4759)

Email: [email protected]

EUS Hours of Operation:

• Monday–Friday: 6 am–6 pm CT
• Saturday–Sunday: Closed

Before you log in to PECOS, you need a valid I&A System user ID and password.

Passwords expire every 60 days. The I&A System tells you the number of days until your password expires. If you attempt to log in to PECOS with an expired password, the system redirects you to the I&A System to reset it.

Solution: Access I&A System or Contact I&A System Help

The I&A System website lets you create an I&A System user ID and password, change your password, and recover forgotten login information. You can also access several resources:

• The I&A FAQs helps you resolve common I&A System problems
• The I&A System Quick Reference Guide provides step-by-step instructions, including screenshots, and information about I&A System features and tools

On the I&A System website, select the Help button in the upper right corner of any webpage for more information on that webpage’s topic.

While using PECOS, you may have questions, experience problems enrolling, or need help completing specific PECOS enrollment application sections.

Solution: Contact Your Medicare Enrollment Contractor

Find detailed enrollment contact information in the Medicare Provider Enrollment Contact List . If you have questions, find your MAC’s website .

Solution: Refer to the CMS Provider Enrollment Assistance Guide

If you don’t know who to call for help, refer to the “Who should I call?” CMS Provider Enrollment Assistance Guide .

Find detailed enrollment contact information in the Medicare Provider Enrollment Contact List .

Organizational providers and suppliers must designate a provider enrollment AO to work in CMS systems, including the I&A System , NPPES , and PECOS . The AO may also authorize Access Managers, Surrogates, and SEUs to use PECOS. Individual providers and suppliers don’t require an AO but can authorize Surrogates and SEUs to work in PECOS. Refer to the I&A System Quick Reference Guide and I&A FAQs for more information on registering for an I&A System account or enrolling as an AO.

We use several provider enrollment systems. Specifically, the I&A System allows you to:

• Use PECOS to enroll in Medicare or to update or revalidate your current enrollment information
• Register to get EHR incentive payments for eligible professionals and hospitals that adopt, use and upgrade, or show meaningful use of certified EHR technology

Before completing PECOS enrollment, create an I&A System account. Organizational providers and suppliers must designate an AO to work in these systems.

Use the same information to enroll in Medicare using PECOS as you would for a paper enrollment application.

• If you don’t have an I&A System account, create your username and password
• Use your username and password to log in to NPPES to register for an NPI
• All Medicare provider enrollees must have an active NPI

Based on your provider type, you may also need this information:

• Personal identifying information, including your legal name on file with the Social Security Administration, date of birth, and SSN
• Legal business name of the provider or supplier organization
• Provider or supplier organization’s TIN; if any person or organization has 5% or more partnership interest or ownership (direct or indirect), you must list them on all enrollment records under your TIN
• Professional license information
• School degrees
• Certificates
• W-2 employees and contracted individuals and organizations with managerial control of the provider or supplier
• Accreditation information
• Surety bond information
• Providers self-designate their Medicare specialty on the Medicare enrollment application (CMS 855-I or CMS 855-O) or PECOS when they enroll in the Medicare Program
• Beginning January 1, 2024, we established new provider specialty codes for dentists
• Current medical practice location
• Federal, state, and local (city or county) business and professional licenses, certificates, and registrations specifically required to operate as a health care facility
• Medical record storage information
• Special payment information
• Bank account information
• Suspension, termination, or revocation of a license to provide health care by a state licensing authority or the Medicaid Program
• Conviction of a federal or state felony within 10 years before enrollment, revalidation, or re-enrollment
• Exclusion or debarment from federal or state health care program participation by the Office of Inspector General (OIG) or other federal or state offices with authority to exclude or sanction a provider (or those listed above)

An application is the paper or electronic form you submit for Medicare Program enrollment approval. After the MAC processes the application, PECOS keeps the enrollment record, which includes all your enrollment application data.

You can’t use PECOS to:

• Change your SSN
• Change a provider’s or supplier’s TIN
• Solely owned PA, PC, or LLC can’t be changed to a sole proprietorship
• Sole proprietorship can’t be changed to a PA, a PC, or an LLC

Submit changes noted above using the appropriate paper Medicare enrollment application .

No. All Fee-for-Service (FFS) providers can apply in PECOS.

PECOS is available 24 hours a day, Monday–Saturday, with scheduled downtime on Sunday. We offer technical support daily, 5 am–8 pm CT.

We encourage you to submit your enrollment application through PECOS because it’s faster and easier, but you may complete and mail the appropriate paper Medicare enrollment application to the address on the Medicare Fee-for-Service Provider Enrollment Contact List :

• Parts A and B Providers: Send forms to your Part A or Part B MAC.
• Home Health and Hospice Providers: Send forms to the Home Health and Hospice Contractor.
• DMEPOS Suppliers Send forms to the National Provider Enrollment (NPE) DMEPOS contractor in your region. Find your NPE contractor .

Even if you submit your application on a paper form, your MAC creates an enrollment record in PECOS.

When you electronically submit your Medicare enrollment application, you’ll get a Submission Confirmation page, which will remind you that the individual provider, or the provider or supplier organization AO or Access Manager must electronically sign the application or upload their signature. You’ll be able to see which MAC is processing your application, your unique application tracking number, and real-time information about your application.

PECOS emails the web tracking ID for the submitted application to each address in the Contact Person section of the application. Remember to verify all your completed signatures with either an electronic signature or uploading certification. Mail any required supporting documentation you didn’t upload during submission to the MAC, and include the PECOS tracking ID.

Create a new enrollment:

• If you change your services, like changing specialties
• If you change your location, causing your MAC to need new state surveys and other documentation (your MAC can determine this)
• If you have a change of ownership
• If a provider is creating a new TIN because of a change of ownership
• If you have provider-based vs. freestanding requirements (find your MAC’s website for more information)

Application Fee & Supporting Documentation

Generally, institutional providers and suppliers, like DMEPOS suppliers and opioid treatment programs, pay an application fee when enrolling, re-enrolling, revalidating, or adding a new practice location.

MACs will only process applications with the proper application fee payment or an approved hardship exception.

If you pay the fee during the 30-day period, the MAC processes the application in the usual manner.

No. When you electronically submit the Medicare enrollment application, a page appears that lists the supporting documentation to complete the enrollment. You can submit all this documentation electronically through PECOS.

Yes, either is acceptable. You must send this information electronically (as supporting documentation uploaded into PECOS).

During the PECOS application process, the Penalties for Falsifying Information page has the same text as the paper Medicare enrollment application and lists the consequences for providing false information. These consequences include criminal and civil penalties, fines, civil monetary penalties, exclusion from federal health care programs, and imprisonment, among others. You must acknowledge this page by selecting the Next Page button before continuing the PECOS submission process.

Enrollment Application Issues

First, make sure you entered your correct SSN, legal name, and date of birth. If you believe you entered the correct information but PECOS doesn’t accept this information, contact the Social Security Administration .

You must report an SSN to enroll in Medicare. If you don’t want to report your SSN over the web, use the appropriate paper Medicare enrollment application .

An Invalid Address error indicates the address entered doesn’t comply with the U.S. Postal Service address standards. This page lets you continue by either saving the address you entered or selecting the address PECOS displays.

As a security feature, PECOS will time out if you’re inactive (you don’t hit any keys on your computer keyboard) for 15 minutes. The system warns you of inactivity after 10 minutes. If it gets no response after 5 additional minutes, the system automatically times you out. Save your work if you anticipate inactivity while applying in PECOS. If you don’t save your work and the system times out, you must start from the beginning.

Submitting Reportable Events

No. If you report a change to existing information, check Change , include the effective date of change, and complete the appropriate fields in the impacted sections.

Yes. Following your initial enrollment, report certain changes (reportable events) to your MAC within 30 calendar days of the change. Report all other changes to your MAC within 90 days.

Report a Medicare enrollment change using PECOS. Physicians and NPPs must report a change of ownership or control (including a change in authorized or delegated official), a change in practice location, and any final adverse legal actions (like a felony or suspension of a federal or state license) within 30 days of the change and report all other changes within 90 days of the change.

Since Medicare pays claims by EFT, the Special Payments address should indicate where all other payment information must go (for example, paper remittance notices or special payments).

Providers and suppliers should report most changes using PECOS or the applicable paper Medicare enrollment application .

No. If you have a new business location, complete a new PECOS or paper application. Each DMEPOS enrollment record can only have 1 current business location.

Revalidations

Revalidation means resubmitting and recertifying your enrollment information.

DMEPOS suppliers must revalidate every 3 years, while all other providers and suppliers generally revalidate every 5 years. We can also conduct off-cycle revalidations . You can revalidate using PECOS or by submitting the appropriate paper Medicare enrollment application .

If you’re currently enrolled, check the Medicare Revalidation List to find your revalidation due date. If you see a due date, submit your revalidation before that date. Your MAC will also send you a revalidation notice.

Due dates are:

• Updated in the Medicare Revalidation List every 60 days at the beginning of the month
• Listed up to 7 months in advance or listed as to be determined (TBD) if the due date is more than 7 months away

Yes. Your MAC will send a revalidation notice 90–120 days before your revalidation due date.

If there’s no due date listed on the Medicare Revalidation List or you didn’t get a MAC letter requesting revalidation, don’t submit your revalidation application. Your MAC will return it to you.

However, if you’re within 2 months of the due date listed on the Medicare Revalidation List and didn’t get a MAC notice to revalidate, submit your revalidation application.

Yes. PECOS lets you review information on file and update and electronically submit your revalidation. If you use PECOS, you need to update only changed information.

If you submit your revalidation after its due date, your MAC may place a hold on your Medicare payments or deactivate your Medicare billing privileges. If the MAC requests additional documentation, respond within 30 days. If you don’t, they may deactivate your Medicare billing privileges.

Revalidation ensures all provider enrollment records are accurate and current. Generally, we don’t take administrative action against a provider or supplier for updating their records even though it wasn’t timely. However, we could take administrative actions, including recovering previous Medicare payments, when a provider or supplier that fails to report the change causes their Medicare enrollment to become ineligible.

PECOS users can’t mail documents that require a signature. When submitting your application, be prepared to send an e-signature or upload your signed documents.

Protect Your Identity & Privacy

You can help protect your professional medical identifiers from identity thieves attempting to defraud the Medicare Program.

Keep PECOS Enrollment Information Current

Log in to PECOS and review your Medicare enrollment information several times a year to ensure no unauthorized changes were made.

PECOS Provides Security

Only you, authorized surrogates, authorized CMS officials, and MACs may enter and view your Medicare PECOS enrollment information. CMS officials and MACs get security standards training and must protect your information. We don’t disclose your Medicare enrollment information to anyone, except when authorized or required by law.

Review & Protect Enrollment Information

Review your Medicare enrollment information in PECOS frequently to ensure it’s accurate, current, and unaltered.

Use your I&A System user ID and password to access PECOS. Keep your ID and password secure.

Protect Yourself & CMS Programs from Fraud

Your NPI and TIN are publicly available information. Use extra caution to monitor and protect your professional and personal information to help prevent fraud and abuse. Also ensure your patients’ personal health information is secure. Refer to these resources:

• Medicare Fraud & Abuse: Prevent, Detect, Report
• Office of Inspector General
• Reporting Medicare fraud & abuse

Take these steps to verify your Medicare enrollment information:

If you suspect your PECOS profile is incorrect due to unauthorized account access, contact your MAC, law enforcement authorities, and your bank. Your MAC and bank can flag your respective accounts for possible fraudulent activity, and law enforcement can begin investigating if and how your accounts were compromised.

Additional Privacy Tips

Take these additional actions to protect your Medicare enrollment information:

• Change your password in the I&A System before accessing PECOS the first time. You can’t change your user ID, but you must change your password every 60 days.
• Review your Medicare enrollment information several times a year to ensure no one changed information without your knowledge. Immediately report changes you didn’t submit.
• Maintain your Medicare enrollment record. Report Medicare enrollment changes known as reportable events, including change of ownership or control , change in practice location, banking arrangements, and any final adverse legal actions.
• Store PECOS copies or paper enrollment applications in a secure location. Don’t allow others access to this information as it contains your personal information, including your date of birth and SSN. Don’t leave copies in a public workspace.
• Enroll in electronic Medicare payments, and ensure they deposit directly into your bank account. We require all providers to use electronic funds transfer (EFT) when enrolling in Medicare, revalidating, or making changes to their enrollment. The most efficient way to enroll in EFT is to complete the EFT information section in PECOS and provide the required supporting documentation. Using EFT allows us to send payments directly to your bank account.

DMEPOS Supplier Requirements

Dmepos supplier standards, accreditation, & surety bond.

To enroll or keep your Medicare billing privileges, all DMEPOS suppliers (except certain exempted professionals) must meet supplier and DMEPOS Quality Standards to become accredited. Certain DMEPOS suppliers must also submit a surety bond .

DMEPOS suppliers (except those exempted eligible professionals and other persons) must be accredited by a CMS-approved accrediting organization before submitting a Medicare enrollment application to the National Provider Enrollment (NPE) DMEPOS contractors .

Each enrolled DMEPOS supplier covered under the Health Insurance Portability and Accountability Act (HIPAA) must name each practice location (if it has more than 1) as a sub-part and make sure each sub-part gets its own NPI.

Individual DMEPOS Suppliers (for example, sole proprietorships)

Physicians, NPPs, and DMEPOS suppliers may use their I&A System user ID and password to access PECOS . If you don’t already have an I&A System account, refer to the I&A System User Registration page and enter the information to open an account. For help, refer to the How to Setup Your Account if you are a Sole Owner section in the I&A System Quick Reference Guide .

As an individual DMEPOS supplier, you don’t need an AO or another authorized user.

Organizational DMEPOS Suppliers System Users

A DMEPOS supplier organization must appoint an AO to manage connections and staff, including appointing and approving other authorized PECOS users. The organization must identify the AO in the enrollment application. The AO must have ownership or managing control in the DMEPOS supplier organization.

Providers Who Solely Order or Certify

Physicians and other eligible professionals must enroll in the Medicare Program or have a valid opt-out affidavit on file to solely order or certify Medicare patient items or services.

Those physicians and other eligible professionals enrolled solely as ordering/certifying providers don’t send billed service claims to a MAC.

Ordering/Certifying Terms

Part B claims use the term ordering/certifying provider to identify the professional who orders or certifies an item or service reported in a claim. These are technically correct terms:

• Providers order non-physician patient items or services, like DMEPOS, clinical lab services, or imaging services
• Providers certify patient home health services

The health care industry uses the terms ordered , referred , and certified interchangeably .

Who Are Eligible Ordering/Certifying Providers?

Physicians or eligible professionals who order or certify Part A or Part B services but don’t want to submit Medicare claims are eligible ordering/certifying providers.

A person already enrolled as a Part B provider may submit claims listing themselves as the ordering/certifying provider without re-enrolling using Medicare Enrollment Application: Enrollment for Eligible Ordering/Certifying Physicians and Other Eligible Professionals (CMS-855O) .

Note: Those who enroll as eligible providers using CMS-855O can’t bill Medicare, and we can’t pay for their services because they have no Medicare billing privileges.

Organizational NPIs don’t qualify, and you can’t use them to order or certify.

Eligible providers must meet these basic conditions:

• Have an individual NPI
• Be enrolled in Medicare in either an approved or opt-out status
• Be an eligible specialty type to order or certify

Denial of Ordering/Certifying Claims

If claims lack a valid individual NPI, MACs deny them if they’re from:

• Clinical labs for ordered tests
• Imaging centers for ordered imaging procedures
• DMEPOS suppliers for ordered DMEPOS
• Part A home health agencies that aren’t ordered or certified by a Doctor of Medicine, Osteopathy, or Podiatric Medicine

If you bill a service that needs an eligible provider and they aren’t on the claim, the MAC will deny the claim. The claim must have a valid NPI and the eligible provider’s name as it appears in PECOS.

If a provider who’s on the Preclusion List prescribes a Medicare Part D drug, drug plans will deny it.

Requirement 1: Get an Individual NPI

The 2 types of NPIs are: Type 1 (individual) and Type 2 (organizational). Medicare allows only Type 1 NPIs to solely order items or certify services. Apply for an NPI through:

• Online Application: Get an I&A System user account. Then apply for an NPI in NPPES .

Requirement 2: Enroll in Medicare in an Approved or Opt-Out Status

Once you have an NPI, use PECOS to verify current Medicare enrollment record information, including your NPI and that you’re approved, or go to the Opt Out Affidavits list to check your status. To opt out of Medicare, submit an affidavit expressing your decision to opt out of the program.

Part C and Part D providers don’t have to enroll in Medicare in an approved or opt-out status.

*We deny certain power mobility device claims if the ordering provider isn’t on our eligible providers list.

Requirement 3: Be Eligible to Order or Certify

The physicians and eligible professionals who may enroll in Medicare solely for ordering or certifying include, but aren’t limited to, physicians and eligible professionals who are:

• Department of Veterans Affairs employees
• Public Health Service employees
• Department of Defense or TRICARE employees
• Indian Health Service or Tribal Organization employees
• Federally Qualified Health Center, Rural Health Clinic, or Critical Access Hospital employees
• Licensed Residents in an approved medical residency program defined in 42 CFR 413.75(b)
• Dentists, including oral surgeons
• Pediatricians
• Retired, licensed physicians

If you’re unsure whether your specific provider specialty qualifies to enroll as an ordering/certifying provider, refer to Section 4 of CMS-855O or find your MAC’s website before submitting a Medicare enrollment application.

Interns & Residents

Claims for items or services ordered or certified by licensed or unlicensed interns and residents must specify a teaching physician’s NPI and name. State-licensed residents may enroll to order or certify and can be listed on claims. If states offer provisional licenses or otherwise permit residents to order/certify, we allow interns and residents to enroll consistent with state law.

Requirement 4: Respond to Requests for More Information

• To see your enrollment status without logging in, go to PECOS and, under Helpful Links , select Application Status .

Requirement 5: Use PECOS to Keep Enrollment Information Current

Report a Medicare enrollment change using PECOS. Providers and suppliers must report a change of ownership or control (including a change in authorized or delegated official), a change in practice location, and any final adverse legal actions (like revocation or suspension of a federal or state license) within 30 days of the change and must report all other changes within 90 days of the change.

Revalidation

Revalidation, or re-submitting and recertifying your enrollment information accuracy, is an important anti-fraud tool. All Medicare-enrolled providers and suppliers must periodically revalidate their enrollment information .

Generally, physicians, including physician organizations, opioid treatment programs, Medicare Diabetes Prevention Program suppliers, and institutional providers, revalidate enrollment every 5 years or when we request it. DMEPOS suppliers must revalidate their enrollment information every 3 years.

PECOS is the most efficient way to revalidate information.

If you’re actively enrolled, go to the Medicare Revalidation List to find your revalidation due date. If you see a due date, submit your revalidation before that date. Your MAC notifies you when it’s time to revalidate. If you submit your revalidation application after the due date, your MAC may hold your Medicare payments or deactivate your billing privileges.

Rebuttal Process

MACs issue Medicare billing privilege deactivations. We permit providers and suppliers to file a rebuttal .

Get more information:

• 42 CFR 424.515
• Provider Enrollment Revalidation Cycle 2 FAQs
• Revalidations (Renewing Your Enrollment)

Large Group Coordination

Groups with more than 200 members can use the Medicare Revalidation List and search by their organization’s name to download group information. Their MAC will send them a letter and spreadsheet that lists the providers linked to their group who must revalidate within 6 months. Large groups should work together to ensure they submit only 1 application from each provider or supplier.

Use these resources to learn how to enroll in the Medicare Program, revalidate your enrollment, or change your enrollment information. Enroll in the Medicare Program to get paid for providing covered patient services. Enroll if you solely order items or certify services.

You can enroll online by using PECOS or the appropriate paper enrollment application you submit to your MAC.

• Get an I&A System user account
• Apply for your NPI in the NPPES
• Enroll in PECOS

Enrollment Forms

If you enroll using a paper application instead of PECOS , search the CMS Forms List to find the form you need and read on page 1, Who Should Submit This Application .

Commonly Used Terms

View the Medicare Learning Network® Content Disclaimer and Department of Health & Human Services Disclosure .

The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department of Health & Human Services (HHS).

Medicare Assignment: Understanding How It Works

Medicare assignment is a term used to describe how a healthcare provider agrees to accept the Medicare-approved amount. Depending on how you get your Medicare coverage, it could be essential to understand what it means and how it can affect you.

What is Medicare assignment?

Medicare sets a fixed cost to pay for every benefit they cover. This amount is called Medicare assignment.

You have the largest healthcare provider network with over 800,000 providers nationwide on Original Medicare . You can see any doctor nationwide that accepts Medicare.

Understanding the differences between your cost and the difference between accepting Medicare and accepting Medicare assignment could be worth thousands of dollars.

Doctors that accept Medicare

Your healthcare provider can fall into one of three categories:

Medicare participating provider and Medicare assignment

Medicare participating providers not accepting medicare assignment, medicare non-participating provider.

More than 97% of healthcare providers nationwide accept Medicare. Because of this, you can see almost any provider throughout the United States without needing referrals.

Let’s discuss the three categories the healthcare providers fall into.

Participating providers are doctors or healthcare providers who accept assignment. This means they will never charge more than the Medicare-approved amount.

Some non-participating providers accept Medicare but not Medicare assignment. This means you can see them the same way a provider accepts assignment.

You need to understand that since they don’t take the assigned amount, they can charge up to 15% more than the Medicare-approved amount.

Since Medicare will only pay the Medicare-approved amount, you’ll be responsible for these charges. The 15% overcharge is called an excess charge. A few states don’t allow or limit the amount or services of the excess charges. Only about 5% of providers charge excess charges.

Opt-out providers don’t accept Original Medicare, and these healthcare providers are in the minority in the United States. If healthcare providers don’t accept Medicare, they won’t be paid by Medicare.

This means choosing to see a provider that doesn’t accept Medicare will leave you responsible for 100% of what they charge you. These providers may be in-network for a Medicare Advantage plan in some cases.

Avoiding excess charges

Excess charges could be large or small depending on the service and the Medicare-approved amount. Avoiding these is easy. The simplest way is to ask your provider if they accept assignment before service.

If they say yes, they don’t issue excess charges. Or, on Medicare.gov , a provider search tool will allow you to look up your healthcare provider and show if they accept Medicare assignment or not.

Medicare Supplement and Medicare assignment

Medigap plans are additional insurance that helps cover your Medicare cost-share . If you are on specific plans, they’ll pay any extra costs from healthcare providers that accept Medicare but not Medicare assigned amount. Most Medicare Supplement plans don’t cover the excess charges.

The top three Medicare Supplement plans cover excess charges if you use a provider that accepts Medicare but not Medicare assignment.

Medicare Advantage and Medicare assignment

Medicare assignment does not affect Medicare Advantage plans since Medicare Advantage is just another way to receive your Medicare benefits. Since your Medicare Advantage plan handles your healthcare benefits, they set the terms.

Most Medicare Advantage plans require you to use network providers. If you go out of the network, you may pay more. If you’re on an HMO, you’d be responsible for the entire charge of the provider not being in the network.

Do all doctors accept Medicare Supplement plans?

All doctors that accept Original Medicare accept Medicare Supplement plans. Some doctors don’t accept Medicare. In this case, those doctors won’t accept Medicare Supplements.

Where can I find doctors who accept Medicare assignment?

Medicare has a physician finder tool that will show if a healthcare provider participates in Medicare and accepts Medicare assignments. Most doctors nationwide do accept assignment and therefore don’t charge the Part B excess charges.

Why do some doctors not accept Medicare?

Some doctors are called concierge doctors. These doctors don’t accept any insurance and require cash payments.

What is a Medicare assignment?

Accepting Medicare assignment means that the healthcare provider has agreed only to charge the approved amount for procedures and services.

What does it mean if a doctor does not accept Medicare assignment?

The doctor can change more than the Medicare-approved amount for procedures and services. You could be responsible for up to a 15% excess charge.

How many doctors accept Medicare assignment?

About 97% of doctors agree to accept assignment nationwide.

Is accepting Medicare the same as accepting Medicare assignment?

No. If a doctor accepts Medicare and accepts Medicare assigned amount, they’ll take what Medicare approves as payment in full.

If they accept Medicare but not Medicare assignment, they can charge an excess charge of up to 15% above the Medicare-approved amount. You could be responsible for this excess charge.

What is the Medicare-approved amount?

The Medicare-approved amount is Medicare’s charge as the maximum for any given medical service or procedure. Medicare has set forth an approved amount for every covered item or service.

Can doctors balance bill patients?

Yes, if that doctor is a Medicare participating provider not accepting Medicare assigned amount. The provider may bill up to 15% more than the Medicare-approved amount.

What happens if a doctor does not accept Medicare?

Doctors that don’t accept Medicare will require you to pay their full cost when using their services. Since these providers are non-participating, Medicare will not pay or reimburse for any services rendered.

Get help avoiding Medicare Part B excess charges

Whether it’s Medicare assignment, or anything related to Medicare, we have licensed agents that specialize in this field standing by to assist.

Give us a call, or fill out our online request form . We are happy to help answer questions, review options, and guide you through the process.

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