A non participating provider is a provider that takes Medicare and is subject to all of the Medicare rules regarding payment and medical necessity. However, a non participating provider does not accept assignment from Medicare. The non participating provider may charge the patient up to the limiting amount. That means that you pay the provider on the date of service. The provider submits the claims to Medicare, and Medicare reimburses the patient 80 percent of the Medicare allowable amount for non participating providers. When you see a non participating provider, it will cost you more on your coinsurance (up to 30% coinsurance instead of 20%) than you would pay a participating provider.
If you have out-of-network benefits, we will give you the information you need so you can submit your claims and get reimbursed.
Please call us at (505) 247-9700 if you have any questions