Participating, Non Participating or Opted Out?

by  Christine Taxin
November 30th, 2017

Is the provider non-par or has he opted out of Medicare? There is a difference. Non-par providers must still submit claims to Medicare, they will then pay the patient directly. If a provider is non-par he can decide on a case by case basis if he will accept assignment for a particular claim, he must also follow all of CMS' regulations and can only bill the patient up to the limiting charge.

If he has opted out neither he nor the patient can send any claims to Medicare (except in very limited emergency situations). In this case, the patient would be entirely responsible for the bill. If this is the case then as the above poster suggested you need to contact the secondary insurer regarding how to bill, otherwise you need to contact your clearinghouse and explain the difference between non-par and opted out because you can still submit claims if you are non-par.

You also need to know how the fees are set up: See example:

Payment Amounts - Participating and Nonparticipating Providers and Suppliers

Amount Participating Provider/Supplier Nonparticipating Provider/Supplier Who Accepts Assignment Nonparticipating Provider/Supplier Who Does Not Accept Assignment
Submitted Amount $250.00 $250.00 $250.00
PFS Allowed Amount $200.00 $190.00 $190.00
80 Percent of PFS Allowed Amount $160.00 $152.00 $152.00
Beneficiary Amount Due to Provider/Supplier (after deductible has been met)

$ 40.00

$ 38.00
$ 66.50
Coinsurance + Limiting Charge Portion
Total Payment to Provider/Supplier (payment for nonassighed claims goes to the beneficiary, who is responsible for paying provider/supplier) $200.00 $190.00 $218.50


Participating, Non Participating or Opted Out?. (2017, November 30). Find-A-Code Articles. Retrieved from

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