• Financial benefits for participating provider/supplier – Medicare allowances for services billed by participating provider/supplier are calculated 5% higher than that for a non-participating provider/supplier. The fee schedule is available on the NHIC website at http://www.medicarenhic.com
• Hospital referrals – Hospital staff referring a Medicare patient to a non-participating provider/supplier for further care on an outpatient basis, where practical, must also identify a participating provider/supplier for the patient.
• Beneficiary referrals – Medicare beneficiaries are given the name, address, specialty and telephone number of participating provider/supplier in their area (via Medicare beneficiary toll-free telephone lines).
• Reminders to beneficiaries – The Medicare Summary Notice (MSN) for non-assigned claims includes a message reminding beneficiaries of the participation program.
• Secondary insurance crossovers – Transfer of paid claim information is provided to secondary insurers (e.g., Medigap plans).
Examples of Medicare allowances for services billed by participating provider/supplier:
Participating Provider Reimbursement
Provider bills Medcare………………………………………… $115.00
Medicare allows (PAR AMT)………………………………….. $90.00
Medicare pays (80%) ………………………………………… $72.00
Coinsurance (20%)……………………………………………. $18.00
Non-Participating Provider Reimbursement
(Provider does not accept assignment on the claim)
Limiting Charge……………………………………………… $100.48
Provider bills Medicare ……………………………………. $100.48
Medicare allows (NON PAR AMT)………………………… $87.37
Medicare pays (80%) to the patient……………………. $69.90
Coinsurance (20%)………………………………………… $17.47