Participating provider VS Non participating provider

Difference between Participating providers Non participating providers

The participating provider can get 80 percent of claims endorsed by Medicare. 20 percent from the medicare coinsurance of patients. But nonparticipating providers cannot expect as contracted providers claims of 80%. However, They can raise their compensation legally by charging the limiting fee. Nonpar providers can also choose the task from medicare.


Par provider vs Nonpar provider


Participating Providers Non participating providers
Enrolled in medicare beneficiary agreement Not Enrolled in medicare agreements. but elect to accept the assignments
Cannot collect more than applicable deductible, co-insurance, copay when the patient is covered. cannot bill the patient more than the allowed charge
Reimbursement is 5 % higher than the nonparticipating provider Reimbursement is 5% lesser than the participating provider
Claim submission is mandatory claim submission is mandatory
Medigap information is transferred. Medigap information is not transferred

Questionnaire flow chart for denial


non participating provider denial

Recommended Action

In short, There can be two scenarios if the claim is denied as a nonparticipating provider check the TIN/PIN from the software. when you find the provider is participating ask the rep to send the claim back for review. if the provider is not participating check whether it is HMO/PPO. when a patient has a PPO plan ask the rep to send the claim back for review. If it is HMO follow the protocol.


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