Can you bill Medicare as a non-participating provider?

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Yes, a non-participating (non-PAR) provider can bill Medicare, because they are still enrolled in the Medicare program.

How Non-Participating Billing Works

  • Claim Submission: Non-PAR providers are legally required to submit a claim to Medicare for any Medicare-covered services they provide to a beneficiary. They cannot charge the patient a fee for submitting this claim.
  • Claim-by-Claim Assignment: Unlike participating providers who always take assignment, a non-PAR provider chooses whether or not to accept assignment on a claim-by-claim basis.
  • If they accept assignment: Medicare pays the provider directly at a slightly lower rate (95% of the standard fee schedule). The provider cannot balance bill the patient beyond the standard coinsurance and deductible.
  • If they do not accept assignment (Unassigned claims): The provider can bill the patient upfront for the services, but they are bound by the limiting charge. They cannot charge more than 115% of Medicare's approved amount for non-PAR providers. Medicare will then reimburse its share directly to the patient.

Note: This is different from an "opt-out" provider, who completely rejects Medicare, signs private contracts, and is barred from billing Medicare entirely. You can verify a doctor's participation details through the official Medicare Provider Lookup tool.

Can you bill Medicare if you are not credentialed?

No, you cannot bill Medicare for services provided by a non-credentialed and unenrolled provider.

⚠️ Consequences of Uncredentialed Billing

  • ❌ Claim denials: Medicare automatically rejects claims from uncredentialed providers.
  • 💸 Revenue loss: Services rendered before approval cannot be collected.
  • 🚨 Fraud risk: Billing under another provider's NPI is illegal.

💡 Compliant Alternatives & Rules

  • 🗓 Hold Claims: Hold pending claims from application submission date.
  • 🔄 Locum Tenens: Use Q6 modifier for temporary substitutes (60-day limit).
  • 💵 Cash-Pay: Restrict care to out-of-pocket or non-insured services.

What is a Medicare nonparticipating provider?

A Medicare nonparticipating provider is a doctor or supplier enrolled in Medicare who chooses not to sign a full participation agreement and decides whether to accept Medicare's assigned rates on a claim-by-claim basis.

How Nonparticipating Providers Work

  • Case-by-Case Assignment: They can choose to accept "assignment" (accepting Medicare's approved amount as payment in full) for some patients or services, but decline it for others.
  • Lower Reimbursement: When they do accept assignment, Medicare pays them 95% of the Medicare Physician Fee Schedule (5% less than participating providers).
  • The Limiting Charge: If they do not accept assignment on a service, they cannot charge whatever they want; they are capped by law at a 15% limiting charge above the Medicare-approved amount.
  • Mandatory Claims Submission: They are still required by law to submit the billing claim to Medicare for covered services, unlike "opt-out" providers.

Non-Par vs. Opt-Out vs. Participating

  • Participating (Par): Always accept assignment, take standard rates, and handle billing directly.
  • Non-Participating (Non-Par): Enrolled in Medicare, submit claims, but can charge extra up to the limiting fee if they decline assignment.
  • Opt-Out: Do not take Medicare at all, require private contracts, and do not bill Medicare.

What will Medicare pay if the physician does not participate in Nonpar?

Medicare pays a non-participating (non-par) physician 95% of the standard Medicare Physician Fee Schedule amount, depending on whether they accept assignment for that specific service.

How Non-Par Payments Work

  • Accepting Assignment on a Claim: If the non-par doctor agrees to accept assignment for a visit, Medicare pays the provider directly 80% of that reduced 95% allowable amount. You are responsible for the remaining 20% coinsurance.
  • Not Accepting Assignment (Unassigned Claims): If the doctor does not accept assignment, they can choose to bill you up to the maximum "limiting charge" (115% of the non-par fee schedule amount). In this case, Medicare sends its 80% reimbursement portion directly to you (the patient) rather than the doctor, and you must pay the physician the full out-of-pocket amount.
  • Difference from Opt-Out: A non-par doctor still participates in Medicare on a case-by-case basis. This is different from an "opt-out" doctor who completely rejects Medicare and requires a private contract where Medicare pays nothing.

Can you bill Medicare as an out of network provider?

You cannot bill original Medicare as a non-enrolled or out-of-network provider if you do not have a Medicare contract and a Provider Transaction Access Number (PTAN).

Original Medicare Rules

  • Non-Participating Providers: You can choose not to join Medicare as a "participating" provider. However, you must still be enrolled in Medicare to submit claims and can only charge up to the government-mandated limiting charge.
  • Opt-Out Providers: You can formally opt out of Medicare by signing a private contract with the patient. You cannot bill Medicare at all, and the patient pays 100% out of pocket.
  • Unenrolled Providers: If you have no Medicare enrollment or PTAN, you cannot submit claims to original Medicare.

Medicare Advantage Out-of-Network Rules

  • Direct Billing: For Medicare Advantage PPO plans, non-network providers can sometimes see plan members, but you typically must follow the plan's specific out-of-network billing guidelines or provide the patient with a superbill/receipt and documentation (like a CMS-1500 form) to submit for their own reimbursement.
  • Payment Limits: Plans are required by the Centers for Medicare & Medicaid Services to pay non-network providers at least Original Medicare fee-for-service rates for out-of-area coverage, and balance billing restrictions often apply.

How Do Non-participating Providers Bill Medicare Patients? - Medicare Made Simple Guide

9 related questions found

Can non-participating providers bill Medicare?

Yes, non-participating providers can and must submit claims to Medicare for all covered services they provide.

How Non-Participating Billing Works

  • Mandatory Submission: Non-participating (non-PAR) providers are legally required to file claims with Medicare for covered services.
  • Assignment Choices: They decide whether to accept Medicare assignment on a claim-by-claim basis.
  • Accepting Assignment: If they accept assignment on a specific claim, Medicare pays the provider directly, and the provider can only charge the patient the standard deductible and coinsurance plus 95% of the approved fee schedule.
  • Not Accepting Assignment: If they do not accept assignment, they can collect up to the limiting charge (115% of the non-participating Medicare-approved amount) directly from the patient at the time of service. Medicare then reimburses the patient directly for their share.

Difference from Opt-Out Providers

  • Non-PAR Providers: Are enrolled in Medicare, have a billing number, and must submit claims to Medicare.
  • Opt-Out Providers: Have completely rejected Medicare, do not submit any claims, and require patients to sign private contracts to pay 100% out of pocket.

What happens if a provider is not credentialed?

If a healthcare provider is not credentialed, they cannot bill insurance companies or receive reimbursement for the patient care services they provide.

Here is what happens when a provider lacks proper credentialing:

Financial and Billing Impacts

  • Reimbursement denials: Insurance plans, Medicaid, and Medicare reject claims submitted by uncredentialed providers.
  • Revenue loss: The practice cannot collect payment for services rendered while waiting for approval, creating large billing gaps.
  • Out-of-pocket patient costs: Patients may be forced to pay completely out-of-pocket if their insurance plan refuses to recognize the provider.

Legal and Compliance Risks

  • Fraud penalties: Submitting claims under a different, credentialed doctor’s National Provider Identifier (NPI) to bypass rules violates the False Claims Act and invites severe fraud investigations.
  • Strict "incident-to" limits: Billing under another provider is only allowed under narrow, highly monitored rules (such as specific on-site physician supervision), and breaking these guidelines triggers audits and fines.
  • Negligent credentialing liability: Healthcare organizations that allow unverified staff to treat patients face high legal exposure to malpractice lawsuits and loss of facility accreditation.

How to enroll in Medicare as a non-participating provider?

To become a non-participating (Non-PAR) Medicare provider, you must enroll in Medicare but avoid signing or submitting the Medicare Participating Physician or Supplier Agreement (CMS-460 form).

New Providers

  • Enroll in Medicare: Submit your initial enrollment application through the online PECOS system or via paper application (CMS-855 series).
  • Do Not Sign CMS-460: By default, new providers start as non-participating unless you explicitly submit the CMS-460 participation agreement with your enrollment.

Existing Participating Providers Switching to Non-PAR

  • Wait for Open Enrollment: Change your status only during the annual enrollment period, which runs from mid-November through December 31.
  • Notify Your MAC: Send written notice to your regional Medicare Administrative Contractor (MAC) stating that you are terminating your participation agreement effective January 1.

Key Rules for Non-PAR Providers

  • Mandatory Claim Submission: You must still submit claims to Medicare for all covered services provided to beneficiaries.
  • Case-by-Case Assignment: You can choose to accept assignment (accept Medicare's allowed amount as full payment) on a claim-by-claim basis.
  • Lower Reimbursement: Non-PAR fee schedules are set at 95% of the standard Medicare-approved amount.
  • Limiting Charges: On unassigned claims, you can balance-bill the patient up to a maximum of 115% of the non-participating Medicare fee schedule.

Who is a non-participating provider?

A non-participating provider is a doctor or facility enrolled in Medicare or a private health plan that has chosen not to sign a formal participation agreement to accept assigned rates as payment in full for every patient.

How Non-Participating Providers Work in Medicare

  • Case-by-Case Choice: They can decide whether to accept Medicare's approved payment amount (accept assignment) on each individual claim.
  • Lower Base Pay: When they do accept assignment, they are reimbursed at 95% of the standard Medicare fee schedule.
  • The Limiting Charge: If they do not accept assignment for a service, they can charge you more than the Medicare-approved amount. This extra amount is capped at a maximum of 15% over the approved rate, known as the limiting charge.
  • Mandatory Billing: They must still submit the official claim paperwork to Medicare for covered services on your behalf.

Difference from Other Provider Types

  • Participating Providers: Sign an agreement to always accept Medicare's approved amount as full payment.
  • Opt-Out Providers: Completely reject Medicare, do not bill the system, and require a private cash contract where you pay 100% out of pocket with zero reimbursement.
  • Commercial Out-of-Network: In private insurance, a non-participating provider is simply an "out-of-network" doctor who has no contract with your specific insurance plan.

What is the difference between a Medicare opt-out and a non-participating provider?

Medicare opt-out providers completely reject the Medicare program and require a private contract where patients pay 100% out-of-pocket, while non-participating providers still enroll in Medicare and submit claims, but can balance bill patients up to 15% above the approved amount.

Opt-Out Providers

  • Relationship with Medicare: Completely disengaged from the Medicare program; they do not bill Medicare or receive reimbursement.
  • Billing and Payment: Patients pay 100% out-of-pocket through a signed Private Contract.
  • Charges: Providers set their own rates with no Medicare limits.
  • Renewals: Must file an opt-out affidavit that automatically renews every two years.

Non-Participating (Non-Par) Providers

  • Relationship with Medicare: Enrolled in Medicare and possess a provider number, but chose not to sign a standard participation agreement.
  • Billing and Payment: Must still submit claims to Medicare for covered services.
  • Charges: Reimbursed at 95% of the Medicare fee schedule and can "balance bill" patients up to a maximum of 15% above the approved amount (the limiting charge).
  • Patient Cost: Responsible for the 5% difference, standard deductibles, coinsurance, and any balance-billing amount up to the limiting charge.