Dealing with Medicare Health Insurance Providers
Part 3, Chapter 9: Medicare and Medicare Related Programs: Medicare Page 2
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Medicare has established a series of rules that apply to outpatient claims related to doctors' office visits and medical tests. For example, Medicare lists an allowable amount for each service, test, or procedure. The specific rules that apply to that allowable amount depend on whether the medical provider -- the doctor or testing center -- is a participating provider or a nonparticipating provider.
A participating provider accepts the Medicare allowable amount as the fee. In that case, the provider is said to accept assignment. The Medicare beneficiary generally pays only the deductible -- if it has not yet been met for the year -- and the co-insurance. Medicare pays the balance. The allowable amount is generally listed on the EOMBS.
A nonparticipating provider does not accept the Medicare allowable amount as the total fee. In that situation, the provider does not accept assignment. A nonparticipating provider is allowed to charge a Medicare beneficiary a maximum of an additional 15% above the Medicare allowable amount (115% of that amount), in addition to the usual deductible and co insurance amounts.
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