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Medicare Assignment: Everything You Need to Know

Medicare assignment.

• Providers Accepting Assignment
• Providers Who Do Not
• Billing Options
• Assignment of Benefits
• How to Choose

Frequently Asked Questions

Medicare assignment is an agreement between Medicare and medical providers (doctors, hospitals, medical equipment suppliers, etc.) in which the provider agrees to accept Medicare’s fee schedule as payment in full when Medicare patients are treated.

This article will explain how Medicare assignment works, and what you need to know in order to ensure that you won’t receive unexpected bills.

fizkes / Getty Images

There are 35 million Americans who have Original Medicare. Medicare is a federal program and most medical providers throughout the country accept assignment with Medicare. As a result, these enrollees have a lot more options for medical providers than most of the rest of the population.

They can see any provider who accepts assignment, anywhere in the country. They can be assured that they will only have to pay their expected Medicare cost-sharing (deductible and coinsurance, some or all of which may be paid by a Medigap plan , Medicaid, or supplemental coverage provided by an employer or former employer).

It’s important to note here that the rules are different for the 29 million Americans who have Medicare Advantage plans. These beneficiaries cannot simply use any medical provider who accepts Medicare assignment.

Instead, each Medicare Advantage plan has its own network of providers —much like the health insurance plans that many Americans are accustomed to obtaining from employers or purchasing in the exchange/marketplace .

A provider who accepts assignment with Medicare may or may not be in-network with some or all of the Medicare Advantage plans that offer coverage in a given area. Some Medicare Advantage plans— health maintenance organizations (HMOs) , in particular—will only cover an enrollee’s claims if they use providers who are in the plan's network.

Other Medicare Advantage plans— preferred provider organizations (PPOs) , in particular—will cover out-of-network care but the enrollee will pay more than they would have paid had they seen an in-network provider.

Original Medicare

The bottom line is that Medicare assignment only determines provider accessibility and costs for people who have Original Medicare. People with Medicare Advantage need to understand their own plan’s provider network and coverage rules.

When discussing Medicare assignment and access to providers in this article, keep in mind that it is referring to people who have Original Medicare.

How to Make Sure Your Provider Accepts Assignment

Most doctors, hospitals, and other medical providers in the United States do accept Medicare assignment.

Provider Participation Stats

According to the Centers for Medicare and Medicaid Services, 98% of providers participate in Medicare, which means they accept assignment.

You can ask the provider directly about their participation with Medicare. But Medicare also has a tool that you can use to find participating doctors, hospitals, home health care services, and other providers.

There’s a filter on that tool labeled “Medicare-approved payment.” If you turn on that filter, you will only see providers who accept Medicare assignment. Under each provider’s information, it will say “Charges the Medicare-approved amount (so you pay less out-of-pocket).”

What If Your Provider Doesn’t Accept Assignment?

If your medical provider or equipment supplier doesn’t accept assignment, it means they haven’t agreed to accept Medicare’s approved amounts as payment in full for all of the services.

These providers can still choose to accept assignment on a case-by-case basis. But because they haven’t agreed to accept Medicare assignment for all services, they are considered nonparticipating providers.

Note that "nonparticipating" does not mean that a provider has opted out of Medicare altogether. Medicare will still pay claims for services received from a nonparticipating provider (i.e., one who does not accept Medicare assignment), whereas Medicare does not cover any of the cost of services obtained from a provider who has officially opted out of Medicare.

If a Medicare beneficiary uses a provider who has opted out of Medicare, that person will pay the provider directly and Medicare will not be involved in any way.

Physicians Who Have Opted Out

Only about 1% of all non-pediatric physicians have opted out of Medicare.

For providers who have not opted out of Medicare but who also don’t accept assignment, Medicare will still pay nearly as much as it would have paid if you had used a provider who accepts assignment. Here’s how it works:

• Medicare will pay the provider 95% of the amount they would pay if the provider accepted assignment.
• The provider can charge the person receiving care more than the Medicare-approved amount, but only up to 15% more (some states limit this further). This extra amount, which the patient has to pay out-of-pocket, is known as the limiting charge . But the 15% cap does not apply to medical equipment suppliers; if they do not accept assignment with Medicare, there is no limit on how much they can charge the person receiving care. This is why it’s particularly important to make sure that the supplier accepts Medicare assignment if you need medical equipment.
• The nonparticipating provider may require the person receiving care to pay the entire bill up front and seek reimbursement from Medicare (using Form CMS 1490-S ). Alternatively, they may submit a claim to Medicare on behalf of the person receiving care (using Form CMS-1500 ).
• A nonparticipating provider can choose to accept assignment on a case-by-case basis. They can indicate this on Form CMS-1500 in box 27. The vast majority of nonparticipating providers who bill Medicare choose to accept assignment for the claim being billed.
• Nonparticipating providers do not have to bill your Medigap plan on your behalf.

Billing Options for Providers Who Accept Medicare

When a medical provider accepts assignment with Medicare, part of the agreement is that they will submit bills to Medicare on behalf of the person receiving care. So if you only see providers who accept assignment, you will never need to submit your own bills to Medicare for reimbursement.

If you have a Medigap plan that supplements your Original Medicare coverage, you should present the Medigap coverage information to the provider at the time of service. Medicare will forward the claim information to your Medigap insurer, reducing administrative work on your part.

Depending on the Medigap plan you have, the services that you receive, and the amount you’ve already spent in out-of-pocket costs, the Medigap plan may pay some or all of the out-of-pocket costs that you would otherwise have after Medicare pays its share.

(Note that if you have a type of Medigap plan called Medicare SELECT, you will have to stay within the plan’s network of providers in order to receive benefits. But this is not the case with other Medigap plans.)

After the claim is processed, you’ll be able to see details in your MyMedicare.gov account . Medicare will also send you a Medicare Summary Notice. This is Medicare’s version of an explanation of benefits (EOB) , which is sent out every three months.

If you have a Medigap plan, it should also send you an EOB or something similar, explaining the claim and whether the policy paid any part of it.

What Is Medicare Assignment of Benefits?

For Medicare beneficiaries, assignment of benefits means that the person receiving care agrees to allow a nonparticipating provider to bill Medicare directly (as opposed to having the person receiving care pay the bill up front and seek reimbursement from Medicare). Assignment of benefits is authorized by the person receiving care in Box 13 of Form CMS-1500 .

If the person receiving care refuses to assign benefits, Medicare can only reimburse the person receiving care instead of paying the nonparticipating provider directly.

Things to Consider Before Choosing a Provider

If you’re enrolled in Original Medicare, you have a wide range of options in terms of the providers you can use—far more than most other Americans. In most cases, your preferred doctor and other medical providers will accept assignment with Medicare, keeping your out-of-pocket costs lower than they would otherwise be, and reducing administrative hassle.

There may be circumstances, however, when the best option is a nonparticipating provider or even a provider who has opted out of Medicare altogether. If you choose one of these options, be sure you discuss the details with the provider before proceeding with the treatment.

You’ll want to understand how much is going to be billed and whether the provider will bill Medicare on your behalf if you agree to assign benefits (note that this is not possible if the provider has opted out of Medicare).

If you have supplemental coverage, you’ll also want to check with that plan to see whether it will still pick up some of the cost and, if so, how much you should expect to pay out of your own pocket.

A medical provider who accepts Medicare assignment is considered a participating provider. These providers have agreed to accept Medicare’s fee schedule as payment in full for services they provide to Medicare beneficiaries. Most doctors, hospitals, and other medical providers do accept Medicare assignment.

Nonparticipating providers are those who have not signed an agreement with Medicare to accept Medicare’s rates as payment in full. However, they can agree to accept assignment on a case-by-case basis, as long as they haven’t opted out of Medicare altogether. If they do not accept assignment, they can bill the patient up to 15% more than the Medicare-approved rate.

Providers who opt out of Medicare cannot bill Medicare and Medicare will not pay them or reimburse beneficiaries for their services. But there is no limit on how much they can bill for their services.

A Word From Verywell

It’s in your best interest to choose a provider who accepts Medicare assignment. This will keep your costs as low as possible, streamline the billing and claims process, and ensure that your Medigap plan picks up its share of the costs.

If you feel like you need help navigating the provider options or seeking care from a provider who doesn’t accept assignment, the Medicare State Health Insurance Assistance Program (SHIP) in your state may be able to help.

A doctor who does not accept Medicare assignment has not agreed to accept Medicare’s fee schedule as payment in full for their services. These doctors are considered nonparticipating with Medicare and can bill Medicare beneficiaries up to 15% more than the Medicare-approved amount.

They also have the option to accept assignment (i.e., accept Medicare’s rate as payment in full) on a case-by-case basis.

There are certain circumstances in which a provider is required by law to accept assignment. This includes situations in which the person receiving care has both Medicare and Medicaid. And it also applies to certain medical services, including lab tests, ambulance services, and drugs that are covered under Medicare Part B (as opposed to Part D).

In 2021, 98% of American physicians had participation agreements with Medicare, leaving only about 2% who did not accept assignment (either as a nonparticipating provider, or a provider who had opted out of Medicare altogether).

Accepting assignment is something that the medical provider does, whereas assignment of benefits is something that the patient (the Medicare beneficiary) does. To accept assignment means that the medical provider has agreed to accept Medicare’s approved fee as payment in full for services they provide.

Assignment of benefits means that the person receiving care agrees to allow a medical provider to bill Medicare directly, as opposed to having the person receiving care pay the provider and then seek reimbursement from Medicare.

Centers for Medicare and Medicaid Services. Medicare monthly enrollment .

Centers for Medicare and Medicaid Services. Annual Medicare participation announcement .

Centers for Medicare and Medicaid Services. Lower costs with assignment .

Centers for Medicare and Medicaid Services. Find providers who have opted out of Medicare .

Kaiser Family Foundation. How many physicians have opted-out of the Medicare program ?

Center for Medicare Advocacy. Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) updates .

Centers for Medicare and Medicaid Services. Check the status of a claim .

Centers for Medicare and Medicaid Services. Medicare claims processing manual. Chapter 26 - completing and processing form CMS-1500 data set .

Centers for Medicare and Medicaid Services. Ambulance fee schedule .

Centers for Medicare and Medicaid Services. Prescription drugs (outpatient) .

By Louise Norris Norris is a licensed health insurance agent, book author, and freelance writer. She graduated magna cum laude from Colorado State University.

What Is Medicare Assignment?

Written by: Rachael Zimlich, RN, BSN

Reviewed by: Eboni Onayo, Licensed Insurance Agent

Key Takeaways

Medicare assignment describes the fee structure that your doctor and Medicare have agreed to use.

If your doctor agrees to accept Medicare assignment, they agree to be paid whatever amount Medicare has approved for a service.

You may still see doctors who don’t accept Medicare assignment, but you may have to pay for your visit up front and submit a claim to Medicare for reimbursement.

You may have to pay more to see doctors who don’t accept Medicare assignment.

How Does Medicare Assignment Work?

What is Medicare assignment ?

Medicare assignment simply means that your provider has agreed to stick to a Medicare fee schedule when it comes to what they charge for tests and services. Medicare regularly updates fee schedules, setting specific limits for what it will cover for things like office visits and lab testing.

When a provider agrees to accept Medicare assignment, they cannot charge more than the Medicare-approved amount. For you, this means your out-of-pocket costs may be lower than if you saw a provider who did not accept Medicare assignment. The provider acknowledges that the amount Medicare set for a particular service is the maximum amount that will be paid.

You may still have to pay a Medicare deductible and coinsurance, but your provider will have to submit a claim to Medicare directly and wait for payment before passing any share of the costs onto you. Doctors who accept Medicare assignment cannot charge you to submit these claims.

Still have questions? GoHealth has the answers you need.

How Do I Know if a Provider Accepts Medicare Assignment?

There are a few levels of commitment when it comes to Medicare assignment.

• Providers who have agreed to accept Medicare assignment sign a contract with Medicare.
• Those who have not signed a contract with Medicare can still accept assignment amounts for services of their choice. They do not have to accept assignment for every service provided. These are called non-participating providers.
• Some providers opt out of Medicare altogether. Doctors who have opted out of Medicare completely or who use private contracts will not be paid anything by Medicare, even if it’s for a covered service within the fee limits. You will have to pay the full cost of any services provided by these doctors yourself.

You can check to see if your provider accepts Medicare assignment on Medicare’s website .

Billing Arrangement Options for Providers Who Accept Medicare

Doctors that take Medicare can sign a contract to accept assignment for all Medicare services, or be a non-participating provider that accepts assignment for some services but not all.

A medical provider that accepts Medicare assignment must submit claims directly to Medicare on your behalf. They will be paid the agreed upon amount by Medicare, and you will pay any copayments or deductibles dictated by your plan.

If your doctor is non-participating, they may accept Medicare assignment for some services but not others. Even if they do agree to accept Medicare’s fee for some services, Medicare will only pay then 95% of the set assignment cost for a particular service.

If your provider does plan to work with Medicare, either the provider or you can submit a claim to Medicare, but you may have to pay the entire cost of the visit up front and wait for reimbursement. They can’t charge you for more than the amount approved by Medicare, but they can charge you above the Medicare-approved amount. This is called the limiting charge, and can be up to 15% more than Medicare-approved amount for non-participating providers.

What Does It Mean When a Provider Does Not Accept Medicare Assignment?

Providers who refuse Medicare assignment can still choose to accept Medicare’s set fees for certain services. These are called non-participating providers.

There are a number of providers who opt out of participating in Medicare altogether; they are referred to as “opt-out doctors”. This means they have signed an opt-out agreement with Medicare and can’t be paid by Medicare at all — even for services normally covered by Medicare. Opt-out contracts last for at least two years. Some of these providers may only offer services to patients who sign contracts.

You do not need to sign a contract with a private provider or use an opt-out provider. There are many options for alternative providers who accept Medicare. If you do choose an opt-out or private contract provider, you will have to pay the full cost of services on your own.

Start your Medicare PlanFit CheckUp today.

Do providers have to accept Medicare assignment?

No. Providers can choose to accept a full Medicare assignment, or accept assignment rates for some services as a non-participating provider. Doctors can also opt out of participating in Medicare altogether.

How much will I have to pay if my provider doesn't accept Medicare assignment?

Some providers that don’t accept assignment as a whole will accept assignment for some services. These are called non-participating providers. For these providers and providers who have completely opted out of Medicare, you will pay the majority of or the full amount for your care.

How do I submit a claim?

If you need to submit your own claim to Medicare, you can call 1-800-MEDICARE or use Form CMS-1490S .

Can my provider charge to submit a claim?

No. Providers are not allowed to charge to submit a claim to Medicare on your behalf.

Lower Costs with Assignment. Medicare.gov.

Fee Schedules . CMS.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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Medicare Frequently Asked Questions

Let’s see if you qualify for Medicare savings today!

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).

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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.

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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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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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U.S. Dept. of Health & Human Services

Medicare Participating Physician Or Supplier Agreement

Guidance for Medicare program to accept assignment of the Medicare Part B payment for all services for which the participant is eligible to accept assignment under the Medicare law and regulations and which are furnished while this agreement is in effect.

Download the Guidance Document

Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: April 01, 2019

HHS is committed to making its websites and documents accessible to the widest possible audience, including individuals with disabilities. We are in the process of retroactively making some documents accessible. If you need assistance accessing an accessible version of this document, please reach out to the [email protected] .

DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.

Concierge care

Medicare doesn't cover membership fees for concierge care (also called concierge medicine, retainer-based medicine, boutique medicine, platinum practice, or direct care).

Your costs in Original Medicare

You pay 100% of the membership fee for concierge care.

Your membership fee depends on the contract or agreement you sign with the doctor or doctor group. Additional state laws and consumer protections may apply. For more information, contact your state’s insurance department or consumer protection bureau.

Concierge care is when a doctor or group of doctors charges you a membership fee before they’ll see you or accept you into their practice. After you pay the membership fee, you may get some services or amenities that Medicare doesn’t cover.

Things to know

Doctors who offer concierge care must still follow all Medicare rules, including the following:

• Doctors who accept assignment  can’t charge you extra for Medicare-covered services. This means your membership fee can’t include additional charges for items or services that Medicare usually covers, unless Medicare won’t pay for the item or service. In this situation, your doctor must give you a written notice called an  "Advance Beneficiary Notice of Noncoverage” (ABN)  listing the services and reasons why Medicare may not pay.
• Doctors who don’t accept assignment can charge you more than the  Medicare-Approved Amount  for Medicare-covered services, but there’s a 15% limit called the " limiting charge ."
• All Medicare doctors (whether or not they accept assignment) can charge you for items and services that Medicare doesn’t cover.

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Healthcare Financing Anti-assignment Limitations

By: Leslie J. Levinson , Robinson & Cole LLP

This article describes how to structure financing transactions for healthcare providers to overcome anti-assignment and collection limitations on Medicare and Medicaid receivables.

THE UNIFORM COMMERCIAL CODE (U.C.C.) GENERALLY prohibits restrictions on assignment, making it possible for secured lenders to obtain a perfected security interest in these assets. However, other regulations make it difficult for lenders to collect on these receivables. Lawyers, therefore, use a double lockbox mechanism to work around these federal regulations. You should be familiar with this structure and its legal status as defined in recent case law.

Introduction

Receivables, or “accounts” as defined under the U.C.C., are a valuable and common asset type to pledge to lenders in secured financings. They are simple to perfect, requiring only a general grant of the asset type in a security agreement along with the filing of a U.C.C. financing statement. However, many contracts that give rise to the underlying receivables also contain restrictions that on their face would prevent their assignment to lenders. These contractual anti-assignment clauses would be broad enough to greatly diminish the value of receivables as a form of collateral.

The U.C.C. solves this by rendering most contractual anti-assignment clauses ineffective. Under U.C.C. § 9-406, a term in an agreement between an account debtor (i.e., the party that owes payment to the borrower under the receivable) and the assignor or borrower that “prohibits, restricts, or requires the consent of the account debtor or person obligated on the promissory note to the assignment or transfer of, or the creation, attachment, perfection, or enforcement of a security interest in, the account” is generally ineffective. A term that would result in a default of a contract if the underlying account is pledged is similarly rendered ineffective. This has allowed for borrowers to freely assign these assets and has made Asset-Based Loan financings more accessible to borrowers with large amounts of receivables.

However, a key aspect to an assignment from a lender’s perspective would be its right to receive payments from the account debtor. The U.C.C. has some lender-friendly provisions here but contains some restrictions relevant to the assignment of Medicare and Medicaid receivables. The anti-assignment override provided by the U.C.C. would not be of use to a lender that is unable to collect on those receivables from an account debtor (i.e., the government) during, say, an exercise of remedies. Fortunately for lenders, U.C.C. § 9-406(a) would require an account debtor to make a payment to an assignee (i.e., a lender) if adequate notice is provided to the account debtor. However, U.C.C. § 9-406(b) limits this right of payment if it is otherwise restricted “under law other than this article.”

In fact, the Medicare and Medicaid anti-assignment provisions, with limited exceptions, prohibit anyone, except the healthcare provider, from receiving payments from federal government healthcare programs. In order to comply with the anti-assignment provisions, a provider cannot assign its right to be paid to any other entity, including its lenders. However, as described below, there are cash-management techniques, which if properly structured, will enable the parties to arrange compliant financing transactions.

Anti-assignment Provisions – The Regulatory Framework

Pursuant to 42 C.F.R. § 424.73, except with respect to certain limited exceptions, “Medicare does not pay amounts that are due a provider to any other person under assignment, or power of attorney, or any other direct payment arrangement.” There are several exceptions to this anti-assignment provision, which apply only under limited circumstances but are generally described as payment to a government agency or entity, payment under assignment established by or in accordance with a court order, and payment to an agent who furnishes billing and collection services to the provider, all subject to certain conditions being met.

There are also specific anti-assignment provisions pertaining to each of Medicare Parts A and B. Part A covers hospital insurance benefits for the aged and disabled, while Part B includes supplementary medical insurance benefits for the aged and disabled. For Part A, 42 U.S.C.S. § 1395g(c) states in relevant part that “No payment which may be made to a provider of services under this title [42 U.S.C.S. § 1395 et seq.] for any service furnished to an individual shall be made to any other person under an assignment or power of attorney . . . ” with certain specified exceptions, such as with respect to an assignment to a government agency. For Part B, 42 U.S.C.S. § 1395u(b)(6) states in relevant part that, with certain listed exceptions, “No payment under this part [42 U.S.C.S. § 1395j et seq.] for a service provided to any individual shall . . . be made to anyone other than such individual or (pursuant to an assignment described in subparagraph (B)(ii) of Paragraph (3)) the physician or other person who provided the service . . . .”

In addition, 42 C.F.R. § 447.10, as outlined in Subsection (a), implements Section 1902(a)(32) of the Social Security Act “which prohibits State payments for Medicaid services to anyone other than a provider or beneficiary, except in specified circumstances.” Pursuant to Subsection (d), “Payment may be made only (1) To the provider; or (2) To the beneficiary if he is a noncash beneficiary eligible to receive the payment under § 447.25,” or as otherwise outlined in other sections of 42 C.F.R. § 447.10 (covering, for example, reassignments and payments to a billing agent, such as a billing service or an accounting firm in specified circumstances).

The Double Lockbox Mechanism

It is crucial for both borrowers and lenders, and their counsel, to understand and comply with all aspects of the anti-assignment provisions. The Medicare Claims Processing Manual (Manual), Chapter 1, Section 30.2.5, provides useful guidance to lenders in dealing with Medicare and Medicaid receivables. Specifically, the Manual states that payments due a provider may be sent to a bank for deposit in such provider’s account if certain conditions are met, including that the account be “in the provider/supplier’s name only and only the provider/supplier may issue any instructions on that account. The bank shall be bound by only the provider/ supplier’s instructions. No other agreement that the provider/ supplier has with a third party shall have any influence on the account. In other words, if a bank is under a standing order from the provider/supplier to transfer funds from the provider/ supplier’s account to the account of a financing entity in the same or another bank and the provider/supplier rescinds that order, the bank honors this rescission notwithstanding the fact that it is a breach of the provider/supplier’s agreement with the financing entity.”

Further, the Manual states that the bank “may provide financing to the provider/supplier, as long as the bank states in writing, in the loan agreement, that it waives its right of offset. Therefore, the bank may have a lending relationship with the provider/supplier and may also be the depository for Medicare receivables.” In accordance with the Manual, despite what a provider and lender may agree to in writing, the lender cannot purchase the provider’s Medicare receivables. Accordingly, in light of the above manual provisions, a common and well-accepted mechanism for providers and lenders to structure payments is to have the provider open multiple deposit accounts, with one in the name of provider that receives only Medicare and Medicaid payments. The provider then enters into a compliant arrangement with the bank that generally vests sole control of the account with the provider while having standing (yet revocable) instructions to sweep the monies from the account into another provider bank account that the lender can access and possibly control. This concept is often referred to as the “double lockbox.” Parties regularly elect to have the sweep occur daily in order to ensure funds are not accumulating in the government payments account.

In setting up a double lockbox, there are various details involved and both providers and lenders need to carefully address those to avoid running afoul of any applicable federal or state restrictions. An example of typical language in loan documents that utilize this double lockbox mechanism is as follows:

If any of the Account Debtors is a Governmental Authority, including, without limitation, Medicare and Medicaid (each a “Governmental Account Debtor”), Borrower shall ensure that all collections of such Accounts shall be paid directly to Accounts # XXXXXX, XXXXXX, XXXXXX, at Lender for Borrower (collectively, the “Governmental Accounts”). All funds deposited into the Governmental Accounts shall be transferred into the Borrower’s Operating Accounts by the close of each business day pursuant to that certain Sweep Account Agreement dated as of the date hereof (as amended, restated, replaced, extended, supplemented or otherwise modified from time to time, the “Sweep Agreement”) by and between Borrower and Lender.

While there has not been a significant amount of litigation concerning the validity of these arrangements, they have typically passed judicial muster. For example, in DFS Secured Healthcare Receivables Tr. v. Caregivers Great Lakes, Inc. , when referring to 42 U.S.C. S. § 1395g(c), the court stated that “On its face, this statute stands only for the proposition that Medicare funds cannot be paid directly by the government to someone other than the provider, but it does not prohibit a third party from receiving Medicare funds if they first flow through the provider.” 1

Further, in Lock Realty Corp. IX v. U.S. Health, LP , the court favorably cited DFS Secured Healthcare Receivables Trust and other cases that support the right to assign Medicare and Medicaid receivables and of third parties to collect on those amounts if they first flow through the provider. 2 These other cases include:

• In re Missionary Baptist Foundation of America, Inc. (affirming the decision of the district court and holding that the bank took a valid security interest in the debtor’s accounts receivable due from medical care payments) 3
• Credit Recovery Systems, LLC v. Hieke (“[T]he Court notes that neither the Medicare nor Medicaid statutes expressly proscribe a provider’s assignment of the general right to receive Medicare or Medicaid receivables to a nonprovider.”) 4
• In re E. Boston Neighborhood Health Ctr. Corp . (“Nothing in these statutes prohibits the Debtor, as provider, from granting a security interest in its receivables under these programs or invalidates such security interests. By prohibiting the governmental insurer from making payment on the receivables to anyone other than the Debtor, the statutes may impair the Defendants’ ability to seek payment on the receivables from the governmental insurer without the provider’s cooperation, but that cooperation may well be available, and the statutes do not impair the Defendants’ ability to enforce their security interests once payment has been issued.”) 5
• In re American Care Corp .(denying junior creditor’s motion to terminate adequate protection payment to senior creditor who was entitled such protection pursuant to its valid security interest in Medicare receivables) 6

The court in Lock Realty Corp. IX , concludes, “The financing arrangements in this are case are valid and in accord with the federal anti-assignment statute, so Lock Realty cannot enforce its judgment to the extent satisfaction would infringe on a superior interest in the receivables.” The court in Lock Realty Corp. IX also provided further insight on proper structuring by stating:

In other words, the intervenors’ rights in the funds flow through Americare since neither party can receive Medicare funds pursuant to their arraignment without subsequent judicial enforcement of the security agreement. Because the financing arrangements don’t provide a non-provider with the opportunity to submit a false claim, the concerns addressed by the anti-assignment statute aren’t implicated.7 A court-ordered assignment pursuant to 42 C.F.R. § 424.90, directing payment from AdminiStar to Health Care Services or National City Bank doesn’t violate federal law.

As the above illuminates, it is both possible and commonplace for lenders to offer financing to healthcare providers using Medicare and Medicaid receivables as collateral despite the existence of the anti-assignment provisions by using well documented, commercially acceptable, and compliant financing and collateral agreements. However, given the continued evolution in the way healthcare services are provided and financed, counsel for both providers and lenders must continue to stay abreast of all applicable laws, rules, regulations, and other interpretive guidance to ensure continuing compliance with all laws applicable to healthcare financings.

Les Levinson is a partner at Robinson & Cole LLP, New York, and Co-Chair of the firm’s Transactional Health Law practice group. He has represented private and public businesses throughout his more than 30-year career. Although Les maintains an active corporate and business law practice, he concentrates on the transactional, regulatory, and compliance representation of healthcare and life science clients, including home care and hospice companies, physician practices, hospitals, information technology and medical device companies, healthcare equipment providers, and healthcare investors and lenders.

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1 . 384 F.3d 338, 350 (7th Cir. 2004). 2 . 2007 U.S. Dist. LEXIS 14578, at *6–8 (N.D. Ind. Feb. 27, 2007). 3 . 796 F.2d 752, 759 (5th Cir. 1986). 4 . 158 F. Supp. 2d 689, 693 (E.D. Va. 2001). 5 . 242 B.R. 562, 573 (Bankr. D. Mass. 1999). 6 . 69 B.R. 66, 67 (N.D. Ill. 1986). 7 . See, e.g. , Bank of Kansas v. Hutchinson Health Services, Inc., 12 Kan. App. 2d 87, 735 P.2d 256, 259 (Kan. Ct. App. 1987).

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