Form CMS-460 (04/) 1 FORM APPROVED OMB NO. 0938-0373DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE PARTICIPATING PHYSICIAN OR SUPPLIER AGREEMENT Name(s) and Address of Participant* National Provider Identi037er (NPI)* *List all names and the NPI under which the participant 037les claims with the Medicare Administrative Contractor (MAC)/carrier with whom this agreement is being 037led. The above named person or organization, called 223the participant,224 hereby enters into an agreement with the 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. 1. Meaning of Assignment: For purposes of this agreement, accepting assignment of the Medicare Part B payment means requesting direct Part B payment from the Medicare program. Under an assignment, the approved charge, determined by the MAC/carrier, shall be the full charge for the service covered under Part B. than the applicable deductible and coinsurance. 2. Effective Date: agreement becomes effective . 3. Term and Termination of Agreement: This agreement shall continue in effect through December 31 following the date the agreement becomes effective and shall be renewed automatically for each 12-month period January 1 through December 31 thereafter unless one of the following occurs: agreement that the participant wishes to terminate the agreement at the end of the current term. In the any calendar year, the agreement shall end on December 31 of that year. for the participant, that the participant has substantially failed to comply with the agreement. In the in writing that the agreement will be terminated at a time designated in the notice. Civil and criminal penalties may also be imposed for violation of the agreement. Signature of participant (or authorized representative of participating organization) Date Title (if signer is authorized representative of organization) Of037ce Phone Number (including area code) Received by (name of carrier) Initials of Carrier Of037cial Effective Date According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0373. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850. American LegalNet, Inc. www.FormsWorkFlow.com DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES INSTRUCTIONS FOR THE MEDICARE PARTICIPATING PHYSICIAN AND SUPPLIER AGREEMENT (CMS-460) To sign a participation agreement is to agree to accept assignment for all covered services that you provide to Medicare patients. WHY PARTICIPATE? If you bill for physicians222 professional services, services and supplies provided incident to physicians222 professional services, outpatient physical and occupational therapy services, diagnostic tests, or radiology services, your Medicare fee schedule amounts are 5 percent higher if you participate. Also, providers receive direct and timely reimbursement from Medicare. Regardless of the Medicare Part B services for which you are billing, participants have 223one stop224 billing for beneficiaries who have Medigap coverage not connected with their employment and who assign both their Medicare and Medigap payments to participants. After we have made payment, Medicare will send the claim on to the Medigap insurer for payment of all coinsurance and deductible amounts due under the Medigap policy. The Medigap insurer must pay the participant directly. Currently, the large majority of physicians, practitioners and suppliers are billing under Medicare participation agreements. DO YOU WANT TO OPT OUT OF MEDICARE? Certain physicians and practitioners who do not want to engage with the Medicare program when treating Medicare beneficiaries may choose to 223opt out224 of Medicare. While Medicare does not pay for covered items or services provided by an 223opt-out224 physician or practitioner, beneficiaries and opt-out physicians or practitioners have the flexibility to set mutually acceptable payment terms through a negotiated private contract. Medicare will still pay opt-out physicians or practitioners for emergency or urgent care services rendered to beneficiaries with whom they have not privately contracted. The opt-out decision applies to all items and services provided by the physician or practitioner to any Medicare beneficiary for the entire opt-out period. A physician or practitioner who chooses to opt-out must do so for a two-year period, which automatically renews for successive two-year periods unless the physician or practitioner affirmatively requests that his or her opt-out status not be renewed. Opt-out physicians and practitioners can offer and enter into arrangements with beneficiaries that would otherwise be prohibited under Medicare. Opt-out physicians and practitioners also need not consider certain Medicare requirements, such as deciding on a case-by-case basis whether to provide an advance beneficiary notice of Medicare non-coverage for services in compliance with Medicare rules and guidance. More information can be found by visiting Opt-Out Affidavits WARNING: YOU CANNOT USE THIS FORM TO OPT OUT! WHEN THE DECISION TO PARTICIPATE CAN BE MADE: 225 Toward the end of each calendar year, all MAC/carriers have an open enrollment period. The open enrollment period generally is from mid-November through December 31. During this period, providers who are currently enrolled in the Medicare Program can change their current participation status beginning the next calendar year on January 1. This is the only time these providers are given the opportunity to change their participation status. These providers should contact their MAC/carrier to learn where to send the agreement, and get the exact dates for the open enrollment period when the agreement will be accepted. Form CMS-460 Instructions (04/) 2 American LegalNet, Inc. www.FormsWorkFlow.com 225 New physicians, practitioners, and suppliers can sign the participation agreement and become a Medicare participant at the time of their enrollment into the Medicare Program. The participation agreement will become effective on the date of filing; i.e., the date the participant mails (post-mark date) the agreement to the carrier or delivers it to the carrier. Contact your MAC/carrier to get the exact dates the participation agreement will be accepted, and to learn where to send the agreement. WHAT TO DO DURING OPEN ENROLLMENT: If you choose to be a participant: 225 Do nothing if you are currently participating, or 225 If you are not currently a Medicare participant, complete the blank agreement (CMS-460) and mail it (or a copy) to each carrier to which you submit Part B claims. (On the form show the name(s) and identification number(s) under which you bill.) If you decide not to participate: 225 Do nothing if you are currently not participating, or 225 If you are currently a participant, write to each carrier to which you submit claims, advising of your termination effective the first day of the next calendar year. This written notice must be postmarked prior to the end of the current calendar year. WHAT TO DO IF YOU222RE A NEW PHYSICIAN, PRACTITIONER OR SUPPLIER: If you choose to be a participant: 225 Complete the blank agreement (CMS-460) and submit it with your Medicare enrollment application to your MAC/carrier. 225 If you have already enrolled in the Medicare program, you have 90 days from when you are enrolled to decide if you want to participate. If you decide to