assignment of benefits form medicare

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Medicare Assignment: Everything You Need to Know

Medicare assignment.

• Providers Accepting Assignment
• Providers Who Do Not
• Billing Options
• Assignment of Benefits
• How to Choose

Frequently Asked Questions

Medicare assignment is an agreement between Medicare and medical providers (doctors, hospitals, medical equipment suppliers, etc.) in which the provider agrees to accept Medicare’s fee schedule as payment in full when Medicare patients are treated.

This article will explain how Medicare assignment works, and what you need to know in order to ensure that you won’t receive unexpected bills.

fizkes / Getty Images

There are 35 million Americans who have Original Medicare. Medicare is a federal program and most medical providers throughout the country accept assignment with Medicare. As a result, these enrollees have a lot more options for medical providers than most of the rest of the population.

They can see any provider who accepts assignment, anywhere in the country. They can be assured that they will only have to pay their expected Medicare cost-sharing (deductible and coinsurance, some or all of which may be paid by a Medigap plan , Medicaid, or supplemental coverage provided by an employer or former employer).

It’s important to note here that the rules are different for the 29 million Americans who have Medicare Advantage plans. These beneficiaries cannot simply use any medical provider who accepts Medicare assignment.

Instead, each Medicare Advantage plan has its own network of providers —much like the health insurance plans that many Americans are accustomed to obtaining from employers or purchasing in the exchange/marketplace .

A provider who accepts assignment with Medicare may or may not be in-network with some or all of the Medicare Advantage plans that offer coverage in a given area. Some Medicare Advantage plans— health maintenance organizations (HMOs) , in particular—will only cover an enrollee’s claims if they use providers who are in the plan's network.

Other Medicare Advantage plans— preferred provider organizations (PPOs) , in particular—will cover out-of-network care but the enrollee will pay more than they would have paid had they seen an in-network provider.

Original Medicare

The bottom line is that Medicare assignment only determines provider accessibility and costs for people who have Original Medicare. People with Medicare Advantage need to understand their own plan’s provider network and coverage rules.

When discussing Medicare assignment and access to providers in this article, keep in mind that it is referring to people who have Original Medicare.

How to Make Sure Your Provider Accepts Assignment

Most doctors, hospitals, and other medical providers in the United States do accept Medicare assignment.

Provider Participation Stats

According to the Centers for Medicare and Medicaid Services, 98% of providers participate in Medicare, which means they accept assignment.

You can ask the provider directly about their participation with Medicare. But Medicare also has a tool that you can use to find participating doctors, hospitals, home health care services, and other providers.

There’s a filter on that tool labeled “Medicare-approved payment.” If you turn on that filter, you will only see providers who accept Medicare assignment. Under each provider’s information, it will say “Charges the Medicare-approved amount (so you pay less out-of-pocket).”

What If Your Provider Doesn’t Accept Assignment?

If your medical provider or equipment supplier doesn’t accept assignment, it means they haven’t agreed to accept Medicare’s approved amounts as payment in full for all of the services.

These providers can still choose to accept assignment on a case-by-case basis. But because they haven’t agreed to accept Medicare assignment for all services, they are considered nonparticipating providers.

Note that "nonparticipating" does not mean that a provider has opted out of Medicare altogether. Medicare will still pay claims for services received from a nonparticipating provider (i.e., one who does not accept Medicare assignment), whereas Medicare does not cover any of the cost of services obtained from a provider who has officially opted out of Medicare.

If a Medicare beneficiary uses a provider who has opted out of Medicare, that person will pay the provider directly and Medicare will not be involved in any way.

Physicians Who Have Opted Out

Only about 1% of all non-pediatric physicians have opted out of Medicare.

For providers who have not opted out of Medicare but who also don’t accept assignment, Medicare will still pay nearly as much as it would have paid if you had used a provider who accepts assignment. Here’s how it works:

• Medicare will pay the provider 95% of the amount they would pay if the provider accepted assignment.
• The provider can charge the person receiving care more than the Medicare-approved amount, but only up to 15% more (some states limit this further). This extra amount, which the patient has to pay out-of-pocket, is known as the limiting charge . But the 15% cap does not apply to medical equipment suppliers; if they do not accept assignment with Medicare, there is no limit on how much they can charge the person receiving care. This is why it’s particularly important to make sure that the supplier accepts Medicare assignment if you need medical equipment.
• The nonparticipating provider may require the person receiving care to pay the entire bill up front and seek reimbursement from Medicare (using Form CMS 1490-S ). Alternatively, they may submit a claim to Medicare on behalf of the person receiving care (using Form CMS-1500 ).
• A nonparticipating provider can choose to accept assignment on a case-by-case basis. They can indicate this on Form CMS-1500 in box 27. The vast majority of nonparticipating providers who bill Medicare choose to accept assignment for the claim being billed.
• Nonparticipating providers do not have to bill your Medigap plan on your behalf.

Billing Options for Providers Who Accept Medicare

When a medical provider accepts assignment with Medicare, part of the agreement is that they will submit bills to Medicare on behalf of the person receiving care. So if you only see providers who accept assignment, you will never need to submit your own bills to Medicare for reimbursement.

If you have a Medigap plan that supplements your Original Medicare coverage, you should present the Medigap coverage information to the provider at the time of service. Medicare will forward the claim information to your Medigap insurer, reducing administrative work on your part.

Depending on the Medigap plan you have, the services that you receive, and the amount you’ve already spent in out-of-pocket costs, the Medigap plan may pay some or all of the out-of-pocket costs that you would otherwise have after Medicare pays its share.

(Note that if you have a type of Medigap plan called Medicare SELECT, you will have to stay within the plan’s network of providers in order to receive benefits. But this is not the case with other Medigap plans.)

After the claim is processed, you’ll be able to see details in your MyMedicare.gov account . Medicare will also send you a Medicare Summary Notice. This is Medicare’s version of an explanation of benefits (EOB) , which is sent out every three months.

If you have a Medigap plan, it should also send you an EOB or something similar, explaining the claim and whether the policy paid any part of it.

What Is Medicare Assignment of Benefits?

For Medicare beneficiaries, assignment of benefits means that the person receiving care agrees to allow a nonparticipating provider to bill Medicare directly (as opposed to having the person receiving care pay the bill up front and seek reimbursement from Medicare). Assignment of benefits is authorized by the person receiving care in Box 13 of Form CMS-1500 .

If the person receiving care refuses to assign benefits, Medicare can only reimburse the person receiving care instead of paying the nonparticipating provider directly.

Things to Consider Before Choosing a Provider

If you’re enrolled in Original Medicare, you have a wide range of options in terms of the providers you can use—far more than most other Americans. In most cases, your preferred doctor and other medical providers will accept assignment with Medicare, keeping your out-of-pocket costs lower than they would otherwise be, and reducing administrative hassle.

There may be circumstances, however, when the best option is a nonparticipating provider or even a provider who has opted out of Medicare altogether. If you choose one of these options, be sure you discuss the details with the provider before proceeding with the treatment.

You’ll want to understand how much is going to be billed and whether the provider will bill Medicare on your behalf if you agree to assign benefits (note that this is not possible if the provider has opted out of Medicare).

If you have supplemental coverage, you’ll also want to check with that plan to see whether it will still pick up some of the cost and, if so, how much you should expect to pay out of your own pocket.

A medical provider who accepts Medicare assignment is considered a participating provider. These providers have agreed to accept Medicare’s fee schedule as payment in full for services they provide to Medicare beneficiaries. Most doctors, hospitals, and other medical providers do accept Medicare assignment.

Nonparticipating providers are those who have not signed an agreement with Medicare to accept Medicare’s rates as payment in full. However, they can agree to accept assignment on a case-by-case basis, as long as they haven’t opted out of Medicare altogether. If they do not accept assignment, they can bill the patient up to 15% more than the Medicare-approved rate.

Providers who opt out of Medicare cannot bill Medicare and Medicare will not pay them or reimburse beneficiaries for their services. But there is no limit on how much they can bill for their services.

A Word From Verywell

It’s in your best interest to choose a provider who accepts Medicare assignment. This will keep your costs as low as possible, streamline the billing and claims process, and ensure that your Medigap plan picks up its share of the costs.

If you feel like you need help navigating the provider options or seeking care from a provider who doesn’t accept assignment, the Medicare State Health Insurance Assistance Program (SHIP) in your state may be able to help.

A doctor who does not accept Medicare assignment has not agreed to accept Medicare’s fee schedule as payment in full for their services. These doctors are considered nonparticipating with Medicare and can bill Medicare beneficiaries up to 15% more than the Medicare-approved amount.

They also have the option to accept assignment (i.e., accept Medicare’s rate as payment in full) on a case-by-case basis.

There are certain circumstances in which a provider is required by law to accept assignment. This includes situations in which the person receiving care has both Medicare and Medicaid. And it also applies to certain medical services, including lab tests, ambulance services, and drugs that are covered under Medicare Part B (as opposed to Part D).

In 2021, 98% of American physicians had participation agreements with Medicare, leaving only about 2% who did not accept assignment (either as a nonparticipating provider, or a provider who had opted out of Medicare altogether).

Accepting assignment is something that the medical provider does, whereas assignment of benefits is something that the patient (the Medicare beneficiary) does. To accept assignment means that the medical provider has agreed to accept Medicare’s approved fee as payment in full for services they provide.

Assignment of benefits means that the person receiving care agrees to allow a medical provider to bill Medicare directly, as opposed to having the person receiving care pay the provider and then seek reimbursement from Medicare.

Centers for Medicare and Medicaid Services. Medicare monthly enrollment .

Centers for Medicare and Medicaid Services. Annual Medicare participation announcement .

Centers for Medicare and Medicaid Services. Lower costs with assignment .

Centers for Medicare and Medicaid Services. Find providers who have opted out of Medicare .

Kaiser Family Foundation. How many physicians have opted-out of the Medicare program ?

Center for Medicare Advocacy. Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) updates .

Centers for Medicare and Medicaid Services. Check the status of a claim .

Centers for Medicare and Medicaid Services. Medicare claims processing manual. Chapter 26 - completing and processing form CMS-1500 data set .

Centers for Medicare and Medicaid Services. Ambulance fee schedule .

Centers for Medicare and Medicaid Services. Prescription drugs (outpatient) .

By Louise Norris Norris is a licensed health insurance agent, book author, and freelance writer. She graduated magna cum laude from Colorado State University.

Does your provider accept Medicare as full payment?

You can get the lowest cost if your doctor or other health care provider accepts the Medicare-approved amount  as full payment for a covered service. This is called “accepting assignment.” If a provider accepts assignment, it’s for all Medicare-covered Part A and Part B services.

Using a provider that accepts assignment

Most doctors, providers, and suppliers accept assignment, but always check to make sure that yours do.

If your doctor, provider, or supplier accepts assignment:

• Your out-of-pocket costs may be less.
• They agree to charge you only the Medicare deductible and coinsurance amount, and usually wait for Medicare to pay its share before asking you to pay your share.
• They have to submit your claim directly to Medicare and can't charge you for submitting the claim.

How does assignment impact my drug coverage?

Using a provider that doesn't accept Medicare as full payment

Some providers who don’t accept assignment still choose to accept the Medicare-approved amount for services on a case-by-case basis. These providers are called "non-participating."

If your doctor, provider, or supplier doesn't accept assignment:

• You might have to pay the full amount at the time of service.
• They should submit a claim to Medicare for any Medicare-covered services they give you, and they can’t charge you for submitting a claim. If they refuse to submit a Medicare claim, you can submit your own claim to Medicare. Get the Medicare claim form .
• They can charge up to 15% over the Medicare-approved amount for a service, but no more than that. This is called "the limiting charge."  

Does the limiting charge apply to all Medicare-covered services?

Using a provider that "opts-out" of Medicare

• Doctors and other providers who don’t want to work with the Medicare program may "opt out" of Medicare.
• Medicare won’t pay for items or services you get from provider that opts out, except in emergencies.
• Providers opt out for a minimum of 2 years. Every 2 years, the provider can choose to keep their opt-out status, accept Medicare-approved amounts on a case-by-case basis ("non-participating"), or accept assignment.

Find providers that opted out of Medicare.

Private contracts with doctors or providers who opt out

• If you choose to get services from an opt-out doctor or provider you may need to pay upfront, or set up a payment plan with the provider through a private contract.
• Medicare won’t pay for any service you get from this doctor, even if it’s a Medicare-covered service.

What are the rules for private contracts?

You may want to contact your  State Health Insurance Assistance Program (SHIP) for help before signing a private contract with any doctor or other health care provider.

What do you want to do next?

• Next step: Get help with costs
• Take action: Find a provider
• Get details: How to get Medicare services

• Individuals myGov is a simple and secure way to access online government services.
• PRODA Log in to access HPOS, Business Hub, Aged Care Provider Portal and a range of other government online services.
• Centrelink Business Online
• Child Support Business Online

Medicare Online for health professionals

Medicare Online cuts paperwork and speeds up payment times.

on this page

What you need to know, key features, assignment of benefit documents, medicare digital claiming return codes, further information.

You can submit patient, bulk bill and Department of Veterans' Affairs claims, and transfer Australian Immunisation Register data, via a secure internet connection.

Payments for bulk billed services are deposited directly into your nominated bank account in 2-3 working days.

It also makes it easier for you to help patients claim their Medicare benefit on the spot. Patients can receive their benefit electronically, usually the next working day, by providing their bank account details to us.

If you already have Medicare Online, it's easy to switch on patient claiming in your software. To find out more, contact us or your software vendor.

If you're using Medicare Online for patient claiming, you don't have to ask patients for bank details. Patients register their bank details with us to claim on the spot at the practice.

Medicare Online:

• can be used for patient claims and bulk bill claims
• allows Online Patient Verification and Online Eligibility Verification
• provides notification of immunisation through the Australian Immunisation Register
• is integrated with practice management software
• requires an internet connection, PC and practice management software
• no batching required
• makes payments within 2-3 working days via electronic funds transfer
• makes payments for patient claims, usually the next working day
• has secure communication using PRODA.

Online functionality offered through Medicare Online specific for Department of Veterans' Affairs claims includes:

• medical and pathology
• in-hospital services, including accommodation, theatre fees and prostheses
• allied health services
• community nursing services
• online checks to see if a patient is known to the Department of Veterans' Affairs.

You no longer need to store assignment of benefit forms at the practice if you’re using Medicare Online.

If we need to confirm that the service was provided to a patient, we’ll seek alternative evidence from you that the service was provided. Evidence may include electronic billing information and notes in practice software appointment records. You can also provide the copy of the assignment of benefit form if your practice chooses to retain these..

The legislative requirements for the assignment of benefit are:

• an agreement must be made between the patient (assignor) and you for the assignment of benefit
• the agreement is evidenced through the use of the assignment of benefit form
• the patient is required to sign the form
• a copy of the agreement must be provided to the patient.

When you submit a claim for Medicare benefits, we use return codes to tell you why the claim was rejected or how the claim was assessed. Web service enabled products will receive a return code with a meaningful message.

Under adaptor technology you’ll continue to receive return codes. Find more information on Medicare digital claiming return codes .

Find out more about:

• Doing business online for health professionals
• Public Key Infrastructure
• Medicare Easyclaim
• Software vendors offering Medicare Online claiming .

This information was printed 22 April 2024 from https://www.servicesaustralia.gov.au/medicare-online-for-health-professionals . It may not include all of the relevant information on this topic. Please consider any relevant site notices at https://www.servicesaustralia.gov.au/site-notices when using this material.

Printed link references

Assignment of benefit and signature requirements for MBS telehealth services

Update from Minister Butler - 6/10/23 Following the RACGP’s representations to Minister Butler, the Minister has advised that he has asked his department to provide options to address concerns about the assignment of benefit for Medicare bulk billed claims, including legislative amendments. The department has informed the Minister that until these changes are made, there are no plans to pursue any broad punitive actions on this issue unless it relates to fraudulent claims against Medicare.

The new assignment of benefit process outlined below remains in effect. The RACGP will provide further updates on this issue in due course.

GPs now need to document verbal consent from bulk billed telehealth patients using an approved form which can be downloaded from the Services Australia website . Previously the Department of Health and Aged Care (DoHAC) said verbal consent for telehealth consultations could be documented in a patient’s clinical notes, but this is no longer the case.

When seeking verbal consent for telehealth services:

• DB4E digital form for electronically transmitted claims that can be claimed through HPOS Bulk Bill Webclaim. In most scenarios a DB4E is the appropriate form to use.
• DB020 digital form to be used with Medicare Bulk Bill Webclaims.
• Obtain verbal consent and explain to the patient how you will document their agreement.
• If the patient agrees, type ‘ patient verbally agreed ’ in the signature field.
• Provide a copy of the form to the patient, ideally by email or text for record keeping.
• Keep a copy of all claims and forms for at least two years. This is for auditing purposes if you are subject to a compliance review.

More information about the new assignment of benefit and signature requirements for Medicare Benefits Schedule (MBS) telehealth services is available on the Services Australia website .

DoHAC have published frequently asked questions for providers on the new requirements, which are available from MBS Online .

What is the assignment of benefit rule?

The requirement for a patient’s signature is considered an important deterrent to fraud (eg claims for services that were not provided). The DoHAC is obligated to enforce these rules under section 20A of the Health Insurance Act 1973.

Compliance and auditing

We have received assurances from the DoHAC that no retrospective compliance activities will be completed. However, it is unclear what compliance measures will be undertaken going forward, so we strongly encourage members to follow the correct processes when providing bulk billed telehealth services. You should keep a copy of all correspondence, claims and forms for at least two years for auditing purposes.

RACGP advocacy: cut the red tape

We know many members see this change as further red tape, and a potential barrier to providing bulk billed care, and we are advocating for a better solution. 

The RACGP considers the need to document consent using a form to be an antiquated requirement that must be urgently reviewed. We will be raising our concerns with the Health Minister and calling for a solution that reflects current workflows in general practice.

Our preference is for verbal consent to remain available for bulk billed telehealth consultations, with a digital solution to record consent which minimises the administrative impact on GPs and practice teams. The digital solution needs to be fully integrated with existing clinical information systems and data so it easily fits in with clinical workflows.

Stay up to date with our advocacy on this issue. We know this is frustrating, and we invite you to share your feedback or questions with us. Please email [email protected] to get in touch and let us know if the RACGP can share your de-identified feedback with the DoHAC. Write to your local MP

RACGP members can write to their local federal MP about changes to assignment of benefit rules using the letter template below. The document has editable fields for you to fill in before sending. Click here to find details of your local MP. You can search by name, postcode or electorate. Download the letter template.

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