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Find-A-Code Articles, Published 2014, August 1

What does accept assignment mean.

by   InstaCode Institute Aug 1st, 2014 - Reviewed/Updated Mar 5th

What does it mean to accept assignment on the CMS 1500 claim form - also called the HCFA 1500 claim form.? Should I accept assignment or not? What are the guidelines for accepting assignment in box 27 of the 1500 claim?

These commonly asked questions should have a simple answer, but the number of court cases indicates that it is not as clear cut as it should be. This issue is documented in the book “Problems in Health Care Law” by Robert Desle Miller. The definition appears to be in the hands of the courts. However, we do have some helpful guidelines for you.

One major area of confusion is the relationship between box 12, box 13 and box 27.  These are not interchangeable boxes and they are not necessarily related to each other.

According to the National Uniform Claim Committee (NUCC), the "Accept Assignment" box indicates that the provider agrees to accept assignment.  It simply says to enter an X in the correct box.  It does NOT define what accepting assignment might or might not mean.

It is important to understand that if you are a participating provider in any insurance plan or program, you must first follow the rules according to the contract that you sign. That contract supersedes any guidelines that are included here.

Medicare Instructions / Guidelines

PARTICIPATING providers MUST accept assignment according to the terms of their contract.  The contract itself states:

“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 Medicare carrier, shall be the full charge for the service covered under Part B.  The participant shall not collect from the beneficiary or other person or organization for covered services more than the applicable deductible and coinsurance.”

By law, the providers or types of services listed below MUST also accept assignment:

• Clinical diagnostic laboratory services;
• Physician services to individuals dually entitled to Medicare and Medicaid;
• Services of physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives, certified registered nurse anesthetists, clinical psychologists, and clinical social workers;
• Ambulatory surgical center services for covered ASC procedures;
• Home dialysis supplies and equipment paid under Method II;
• Ambulance services;
• Drugs and biologicals; and
• Simplified Billing Roster for influenza virus vaccine and pneumococcal vaccine.

NON-PARTICIPATING providers can choose whether to accept assignment or not, unless they or the service they are providing is on the list above.

The official Medicare instructions regarding Boxes 12 and 13 are:

“Item 12 – The patient's signature authorizes release of medical information necessary to process the claim. It  also authorizes payments of benefits  to the provider of service or supplier when the provider of service or supplier accepts assignment on the claim.” “Item 13 - The patient’s signature or the statement “signature on file” in this item  authorizes payment of medical benefits  to the physician or supplier. The patient or his/her authorized representative signs this item or the signature must be on file separately with the provider as an authorization. However, note that when payment under the Act can only be made on an assignment-related basis or when payment is for services furnished by a participating physician or supplier, a patient’s signature or a “signature on file” is not required in order for Medicare payment to be made directly to the physician or supplier.”

Regardless of the wording on these instructions stating that it authorizes payments to the physician, this is not enough to ensure that payment will come directly to you instead of the patient.To guarantee payment comes to you, you MUST accept assignment.

Under Medicare rules, PARTICIPATING providers are paid at 80% of the  physician fee schedule allowed amount  and NON-participating providers are paid at 80% of the allowed amount, which is 5% less than the full Allowed amount for participating providers. Only NON-participating providers may "balance bill" the patient for any amounts not paid by Medicare, however, they are subject to any state laws regarding balance billing.

TIP: If you select YES, you may or may not be subject to a lower fee schedule, but at least you know the payment is  supposed  to come to you.

NON-MEDICARE Instructions / Guidelines

PARTICIPATING providers MUST abide by the terms of their contract.  In most cases, this includes the requirement to accept assignment on submitted claims.

NON-PARTICIPATING providers have the choice to accept or not accept assignment.

YES means that payment should go directly to you instead of the patient.  Generally speaking, even if you have an assignment of benefits from the patient (see box 12 & 13), payment is ONLY guaranteed to go to you IF you accept assignment.

NO is appropriate for patients who have paid for their services in full so they may be reimbursed by their insurance.  It generally means payment will go to the patient.

What Does Accept Assignment Mean?. (2014, August 1). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/what-does-accept-assignment-mean-34840.html

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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.

Hospital Billers.com

Improving your hospital revenue cycle, what does accept assignment mean.

admin / December 12, 2012 Leave a Comment

What does it mean to accept assignment on the CMS 1500 claim form – also called the HCFA 1500 claim form.? Should I accept assignment or not? What are the guidelines for accepting assignment in box 27 of the 1500 claim?

These commonly asked questions should have a simple answer, but the number of court cases indicates that it is not as clear cut as it should be. This issue is documented in the book “Problems in Health Care Law” by Robert Desle Miller. The definition appears to be in the hands of the courts. However, we do have some helpful guidelines for you.

One major area of confusion is the relationship between box 12, box 13 and box 27.  These are not interchangeable boxes and they are not necessarily related to each other.

According to the National Uniform Claim Committee (NUCC), the “Accept Assignment” box indicates that the provider agrees to accept assignment.  It simply says to enter an X in the correct box.  It does NOT define what accepting assignment might or might not mean.

It is important to understand that if you are a participating provider in any insurance plan or program, you must first follow the rules according to the contract that you sign. That contract superceeds any guidelines that are included here.

Medicare Instructions / Guidelines

PARTICIPATING providers MUST accept assignment according to the terms of their contract.  The contract itself states:

“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 Medicare carrier, shall be the full charge for the service covered under Part B.  The participant shall not collect from the beneficiary or other person or organization for covered services more than the applicable deductible and coinsurance.”

By law, the providers or types of services listed below MUST also accept assignment:

• Clinical diagnostic laboratory services;
• Physician services to individuals dually entitled to Medicare and Medicaid;
• Services of physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives, certified registered nurse anesthetists, clinical psychologists, and clinical social workers;
• Ambulatory surgical center services for covered ASC procedures;
• Home dialysis supplies and equipment paid under Method II;
• Ambulance services;
• Drugs and biologicals; and
• Simplified Billing Roster for influenza virus vaccine and pneumococcal vaccine.

NON-PARTICIPATING providers can choose whether to accept assignment or not, unless they or the service they are providing is on the list above.

The official Medicare instructions regarding Boxes 12 and 13 are:

“Item 12 – The patient’s signature authorizes release of medical information necessary to process the claim. It also authorizes payments of benefits to the provider of service or supplier when the provider of service or supplier accepts assignment on the claim.” “Item 13 – The patient’s signature or the statement “signature on file” in this item authorizes payment of medical benefits to the physician or supplier. The patient or his/her authorized representative signs this item or the signature must be on file separately with the provider as an authorization. However, note that when payment under the Act can only be made on an assignment-related basis or when payment is for services furnished by a participating physician or supplier, a patient’s signature or a “signature on file” is not required in order for Medicare payment to be made directly to the physician or supplier.”

Regardless of the wording on these instructions stating that it authorizes payments to the physician, this is not enough to ensure that payment will come directly to you instead of the patient.To guarantee payment comes to you, you MUST accept assignment.

Under Medicare rules, PARTICIPATING providers are paid at 80% of the physician fee schedule allowed amount and NON-participating providers are paid at 80% of the allowed amount, which is 5% less than the full Allowed amount for participating providers. Only NON-participating providers may “balance bill” the patient for any amounts not paid by Medicare, however, they are subject to any state laws regarding balance billing.

NON-MEDICARE Instructions / Guidelines

PARTICIPATING providers MUST abide by the terms of their contract.  In most cases, this includes the requirement to accept assignment on submitted claims.

NON-PARTICIPATING providers have the choice to accept or not accept assignment.

YES means that payment should go directly to you instead of the patient.  Generally speaking, even if you have an assignment of benefits from the patient (see box 12 & 13), payment is ONLY guaranteed to go to you IF you accept assignment.

NO is appropriate for patients who have paid for their services in full so they may be reimbursed by their insurance.  It generally means payment will go to the patient.

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Accepting Assignment: HCFA 1500 claim form Boxes 27 and 13

As a provider, you have the option to accept or decline assignment of benefits in chirofusion..

When adding a new Payer in ChiroFusion, you have the ability to specify whether or not you are accepting assignment. By accepting assignment of benefits, the Payer will remit payment directly to you and not the patient. Conversely, if you choose to not accept assignment, the Payer will remit payment directly to the patient. 

You can specify assignment for a particular Payer in ChiroFusion in Settings > Add/Edit Insurance Company > Clearinghouse Details. By default, this selection will apply to all patients associated with this Payer and place the "Signature on File" in Box 13 if necessary.

Insurance Company Settings:

Patient Specific Settings:  

When 'Assignment' is checked in the global insurance settings, it will apply to all patients who are covered by that insurance policy. You have the ability to deselect this box for a specific patient if need be.

In Billing For Refiling Claims: 

You can edit this directly in the HCFA Claim tab and it will update all claims pertaining to specific patients.

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

What Is Medicare Assignment?

Written by: Rachael Zimlich, RN, BSN

Reviewed by: Eboni Onayo, Licensed Insurance Agent

Key Takeaways

Medicare assignment describes the fee structure that your doctor and Medicare have agreed to use.

If your doctor agrees to accept Medicare assignment, they agree to be paid whatever amount Medicare has approved for a service.

You may still see doctors who don’t accept Medicare assignment, but you may have to pay for your visit up front and submit a claim to Medicare for reimbursement.

You may have to pay more to see doctors who don’t accept Medicare assignment.

How Does Medicare Assignment Work?

What is Medicare assignment ?

Medicare assignment simply means that your provider has agreed to stick to a Medicare fee schedule when it comes to what they charge for tests and services. Medicare regularly updates fee schedules, setting specific limits for what it will cover for things like office visits and lab testing.

When a provider agrees to accept Medicare assignment, they cannot charge more than the Medicare-approved amount. For you, this means your out-of-pocket costs may be lower than if you saw a provider who did not accept Medicare assignment. The provider acknowledges that the amount Medicare set for a particular service is the maximum amount that will be paid.

You may still have to pay a Medicare deductible and coinsurance, but your provider will have to submit a claim to Medicare directly and wait for payment before passing any share of the costs onto you. Doctors who accept Medicare assignment cannot charge you to submit these claims.

Find the Medicare Plan that works for you.

How Do I Know if a Provider Accepts Medicare Assignment?

There are a few levels of commitment when it comes to Medicare assignment.

• Providers who have agreed to accept Medicare assignment sign a contract with Medicare.
• Those who have not signed a contract with Medicare can still accept assignment amounts for services of their choice. They do not have to accept assignment for every service provided. These are called non-participating providers.
• Some providers opt out of Medicare altogether. Doctors who have opted out of Medicare completely or who use private contracts will not be paid anything by Medicare, even if it’s for a covered service within the fee limits. You will have to pay the full cost of any services provided by these doctors yourself.

You can check to see if your provider accepts Medicare assignment on Medicare’s website .

Billing Arrangement Options for Providers Who Accept Medicare

Doctors that take Medicare can sign a contract to accept assignment for all Medicare services, or be a non-participating provider that accepts assignment for some services but not all.

A medical provider that accepts Medicare assignment must submit claims directly to Medicare on your behalf. They will be paid the agreed upon amount by Medicare, and you will pay any copayments or deductibles dictated by your plan.

If your doctor is non-participating, they may accept Medicare assignment for some services but not others. Even if they do agree to accept Medicare’s fee for some services, Medicare will only pay then 95% of the set assignment cost for a particular service.

If your provider does plan to work with Medicare, either the provider or you can submit a claim to Medicare, but you may have to pay the entire cost of the visit up front and wait for reimbursement. They can’t charge you for more than the amount approved by Medicare, but they can charge you above the Medicare-approved amount. This is called the limiting charge, and can be up to 15% more than Medicare-approved amount for non-participating providers.

What Does It Mean When a Provider Does Not Accept Medicare Assignment?

Providers who refuse Medicare assignment can still choose to accept Medicare’s set fees for certain services. These are called non-participating providers.

There are a number of providers who opt out of participating in Medicare altogether; they are referred to as “opt-out doctors”. This means they have signed an opt-out agreement with Medicare and can’t be paid by Medicare at all — even for services normally covered by Medicare. Opt-out contracts last for at least two years. Some of these providers may only offer services to patients who sign contracts.

You do not need to sign a contract with a private provider or use an opt-out provider. There are many options for alternative providers who accept Medicare. If you do choose an opt-out or private contract provider, you will have to pay the full cost of services on your own.

Start your Medicare PlanFit CheckUp today.

Do providers have to accept Medicare assignment?

No. Providers can choose to accept a full Medicare assignment, or accept assignment rates for some services as a non-participating provider. Doctors can also opt out of participating in Medicare altogether.

How much will I have to pay if my provider doesn't accept Medicare assignment?

Some providers that don’t accept assignment as a whole will accept assignment for some services. These are called non-participating providers. For these providers and providers who have completely opted out of Medicare, you will pay the majority of or the full amount for your care.

How do I submit a claim?

If you need to submit your own claim to Medicare, you can call 1-800-MEDICARE or use Form CMS-1490S .

Can my provider charge to submit a claim?

No. Providers are not allowed to charge to submit a claim to Medicare on your behalf.

Lower Costs with Assignment. Medicare.gov.

Fee Schedules . CMS.gov.

This website is operated by GoHealth, LLC., a licensed health insurance company. The website and its contents are for informational and educational purposes; helping people understand Medicare in a simple way. The purpose of this website is the solicitation of insurance. Contact will be made by a licensed insurance agent/producer or insurance company. Medicare Supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program. Our mission is to help every American get better health insurance and save money. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.

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CMS-1500 Claim Form Cheat Sheet

Here is a breakdown of each box on the cms-1500 and where they populate from within your unified practice account..

Jump to: 

• Boxes #1 through #13
• Boxes #14 through #23
• Box #24a-#24j
• Boxes #25 through #33b

Box Number: 1 - Insurance Name Where this populates from: Billing Info > Billing Preferences > Insurance Type Description: Where the type of health insurance coverage applicable to this claim is selected. There are seven plan types to select from, by checking the appropriate box. Only one plan type is allowed to be selected.

Box Number: 1a - Insured’s ID Number Where this populates from: Patient File > Insurance tab > Card Info, ID on Card (patient can fill this out during onboarding if you are accepting insurance info). Description: Where the insured's ID number is entered as shown on their ID card for the payer to which the claim is being submitted. 

Box Number: 2 - Patient’s Name Where this populates from: Personal tab of Patient File Description: Where the patient's full name is entered as Last Name, First Name, Middle Initial , separated by commas.

Box Number: 3 - Patient’s Birthdate and Sex Where this populates from: Personal tab of Patient File Description: Where the patient's 8-digit birth date is entered in the format MMDDYYYY. As well, the appropriate box should be marked indicating the sex (gender) of the patient. Only one box can be marked.

Box Number: 4 - Insured’s Name Where this populates from: Personal tab of Patient File OR if covered under someone else, Patient File > Insurance Tab > Card Info > ID on Card (patient can fill this out during onboarding if you are accepting insurance info). Description: Where the insured's full name is entered as Last Name, First Name, Middle Initial , separated by commas.

Box Number: 5 - Patient’s Address Where this populates from: Personal tab of Patient File Description: Where the patient's address information is entered. This is the patient's permanent residence. The first line is for the street address. The second line is for the city and state. The third line is for the zip code and phone number.

Box Number: 6 - Patients relationship to Insured Where this populates from: Insurance tab of the Patient File (If "Covered under someone else's insurance plan?" is switched to Yes OR patient can fill out during onboarding). Description: Where the patient's relationship to the insured is entered. Only one box can be marked.

Box Number: 7 - Insured Address Where this populates from: Personal tab of Patient File OR Patient File >   Insurance Tab > Insured under someone else fields. Description: Where the patient's address information is entered. This is the patient's permanent residence. The first line is for the street address. The second line is for the city and state. The third line is for the zip code and phone number.

Box Number: 8 - Reserved for NUCC Use Where this populates from: can not be modified within Unified Practice Description: Reserved field. It was previously used to report Patient Status. Patient Status no longer exists, so this field has been eliminated.

Box Number: 9 - Other Insured’s Name Where this populates from: Insurance tab must have Primary/Secondary/other insurance info filled out. Then in Billing Info > Billing Preferences , select Primary and Secondary insurances from the drop-down boxes. Description: Indicates that there is a holder of another policy that may cover the patient. The insured's name is entered as Last Name, First Name, Middle Initial, separated by commas. If Box 11d is marked, complete boxes 9, 9a, and 9d, otherwise leave blank.

Box Number: 9a - Other Insured's Policy or Group Number Where this populates from: Insurance tab must have Primary/Secondary/other insurance info filled out. Then in Billing Info > Billing Preferences , select Primary and Secondary insurances from the drop-down boxes. Description: The other insured's policy or group number as it appears on the insured's health care identification card for secondary insurance. If Box 11d is marked, complete boxes 9, 9a, and 9d, otherwise leave blank. 

Box Number: 9b - Reserved for NUCC Use Where this populates from: can not be modified within Unified Practice Description: Box 9b is now a reserved field. It was previously used to report Other Insured's Date of Birth, Sex . Other Insured's Date of Birth, Sex no longer exists, so this field has been eliminated.

Box Number: 9c - Reserved for NUCC Use Where this populates from: can not be modified within Unified Practice Description: Box 9c is now a reserved field. It was previously used to report Employer’s Name or School Name . Employer’s Name or School Name no longer exists, so this field has been eliminated.

Box Number: 9d - Insurance Plan Name or Program Name Where this populates from: can not be modified within Unified Practice Description: Box 9d is the name of the insurance plan or program of the other insured as indicated in Box 9. If Box 11d is marked, complete boxes 9, 9a, and 9d, otherwise leave blank.

Box Number: 10 - Is Patient's Condition Related To Where this populates from: Billing Info > Billing Preferences > Is Patient's condition related to (this carries over from treatment to treatment). Description: Indicate whether the patient’s illness or injury is related to employment, auto accident, or other accident. Only one box on each line can be marked.  Any item marked “YES” indicates there may be other applicable insurance coverage that would be primary, such as automobile liability insurance. Primary insurance information must then be shown in Box 11.

Box Number: 10a - Employment Where this populates from: Employment (current or previous) would indicate that the condition is related to the patient’s job or workplace. Description: Indicate whether the patient’s illness or injury is related to employment, auto accident, or other accident. Only one box on each line can be marked.  Any item marked YES  indicates there may be other applicable insurance coverage that would be primary, such as automobile liability insurance. Primary insurance information must then be shown in Box 11.

Box Number: 10b - Auto Accident Where this populates from: Auto accident would indicate that the condition is the result of an automobile accident. The state postal code where the accident occurred must be reported if YES  is marked in 10b for “Auto Accident.” Description: Indicate whether the patient’s illness or injury is related to employment, auto accident, or other accident. Only one box on each line can be marked.  Any item marked YES  indicates there may be other applicable insurance coverage that would be primary, such as automobile liability insurance. Primary insurance information must then be shown in Box 11.

Box Number: 10c - Other Accident Where this populates from: Other accident would indicate that the condition is the result of any other type of accident. Description: Indicate whether the patient’s illness or injury is related to employment, auto accident, or other accident. Only one box on each line can be marked.  Any item marked YES  indicates there may be other applicable insurance coverage that would be primary, such as automobile liability insurance. Primary insurance information must then be shown in Box 11.

Box Number:  10d - Reserved for Local Use Where this populates from: can not be modified within Unified Practice Description: Used to identify additional information about the patient’s condition or the claim. When required by payers to provide the sub-set of Condition Codes approved by the NUCC, enter the Condition Code in this field.

Box Number: 11 - Insured Policy Group or FECA Number Where this populates from: Billing Info > Billing Preferences > select which company is being used as Primary for this visit. Description: The insured's policy or group number as it appears on the insured's health care identification card.

Box Number: 11a - Insured Date of Birth and Sex Where this populates from: Personal tab of Patient File Description: Where the insured's 8-digit date of birth in the format MMDDYYYY is entered and a box indicating the insured's gender is marked.

Box Number: 11b - Other Claim ID (Designated by NUCC) Where this populates from: can not be modified within Unified Practice Description: The other claim ID. Claim identifiers are designated by the NUCC.

Box Number: 11c - Insurance Plan Name Or Program Name Where this populates from: Insurance tab of Patient File by selecting the Insurance Plan (goes for all types). Description: The name of the insurance plan or program of the insured. Some payers require an identification number of the primary insurer rather than the name in this field.

Box Number: 11d - Is there another Health Benefit Plan Where this populates from: Billing Info > Billing Preferences > Secondary Insurance Description: If Box 11d is marked, complete boxes 9, 9a, and 9d, otherwise leave blank. This specifies if there is another health benefit plan attached to this claim. Mark the appropriate box ( Yes or No ). Only one box can be marked.

Box Number: 12 - Patients or Authorized Person’s Signature Where this populates from: Billing Info > Billing Preferences >  Signature Date . If switched to Yes, you can enter the date. Otherwise, this is left blank. Description: Where the signature and date indicating authorization to release any medical information needed to process and/or adjudicate the claim. This can be done by entering Signature on File , SOF or the actual signature.

Box Number: 13 - Insured’s or Authorized Person’s Signature Where this populates from: This is automatically populated by Unified Practice with Signature on File. Description: Where the signature indicating authorization of payment for medical benefits to the provider of service. This can be done by entering Signature on File , SOF  or the actual signature.

Box Number: 14 - Date of Current Illness, Injury, or Pregnancy Where this populates from: Billing Info > Billing Preferences > Onset Date Description: Identifies the first date of onset of illness, the actual date of injury, or the LMP for pregnancy. Enter the 6-digit (MM│DD│YY) or 8-digit (MM│DD│YYYY) date of the first date of the present illness, injury, or pregnancy. For pregnancy, use the date of the last menstrual period (LMP) as the first date. Enter the applicable qualifier to identify which date is being reported.

Box Number: 15 - Other Date Where this populates from: Billing Info > Billing Preferences > Other Date Description: Where another date related to the patient’s condition or treatment is entered. Enter the applicable qualifier to identify which date is being reported. 454 Initial Treatment, 304 Latest Visit or Consultation, 453 Acute Manifestation of a Chronic Condition, 439 Accident, 455 Last X-ray, 471 Prescription, 090 Report Start (Assumed Care Date), 091 Report End (Relinquished Care Date), 444 First Visit or Consultation.

Box Number: 16 - Dates patient unable to work in current occupation Where this populates from: can not be modified within Unified Practice Description: Where the time span the patient is, or was, unable to work is entered if the patient is employed and is unable to work in their current occupation. A 6-digit (MM│DD│YY) or 8-digit (MM│DD│YYYY) date must be shown for the “from–to” dates that the patient is unable to work. An entry in this field may indicate employment-related insurance coverage.

Box Number: 17 - Name of Referring Provider or other Source Where this populates from: [1.] Patient File > Personal Tab >   Edit > Referring Provider [2.] Billing Info > Billing Preferences > Fill in referring providers details  toggle switched to Yes Description: Where the name of the referring provider, ordering provider, or supervising provider who referred, ordered or supervised the service(s) or supply(ies) on the claim. The qualifier indicates the role of the provider being reported. Enter the name (First Name, Middle Initial, Last Name) followed by the credentials of the professional who referred or ordered the service(s) or supply(ies) on the claim. Enter the applicable qualifier to the left of the vertical dotted line to identify which provider is being reported. DN Referring Provider, DK Ordering Provider

Box Number: 17a Where this populates from: This field can not be populated from Unified Practice

Box Number: 17b - NPI Where this populates from: Patient File > Personal Tab > Edit > Referring Provider > Add new provider > NPI Description: Where the NPI number of the referring, ordering, or supervising provider is entered. The NPI number refers to the HIPAA National Provider Identifier number.

Box Number: 18 - Hospitalization dates related to current services Where this populates from: can not be modified within Unified Practice Description: Where you would refer to an inpatient stay and indicates the admission and discharge dates associated with the service(s) on the claim. Enter the inpatient 6-digit (MM│DD│YY) or 8-digit (MM│DD│YYYY) hospital admission date followed by the discharge date (if discharge has occurred). If not discharged, leave discharge date blank. This date is when a medical service is furnished as a result of, or subsequent to, a related hospitalization.

Box Number: 19 -  Additional Claim Information Where this populates from: Billing Info > Billing Preferences , Additional Claim Information Description: Used to identify additional information about the patient’s condition or the claim. Please refer to the most current instructions from the public or private payer regarding the use of this field. Some payers ask for certain identifiers in this field. If identifiers are reported in this field, enter the appropriate qualifiers describing the identifier.

Box Number: 20 - Outside Lab, $ charges Where this populates from: Billing Info > Billing Preferences > Outside Lab Description: Used to indicate that services have been rendered by an independent provider.

Box Number: 21- Diagnostic or Nature of Illness or Injury (ICD Ind) Where this populates from: Billing Info > ICD codes Description: Used to identify the applicable ICD indicator to specify which version of ICD codes are being reported. 9 ICD-9 0 ICD-10 Box 21, Lines A through L, are used to indicate the sign, symptom, complaint, or condition of the patient relating to the service(s) on the claim. Up to 12 ICD-9-CM or ICD-10-CM diagnosis codes can be entered.

Box Number: 22 - Resubmission Code, Original Ref No. Where this populates from: Billing Info > Billing Preferences > Resubmission code (left), Original reference number (right) Description: Used to list the original reference number for resubmitted/corrected claims. When resubmitting a claim, enter the appropriate bill frequency code left justified in the left-hand side of the field. 6 Corrected Claim 7 Replacement of prior claim 8 Void/cancel of prior claim

Box Number: 23 - Prior Authorization number Where this populates from: Patient File > Insurance tab > Prior authorization turned on > Authorization # Description: Used to show the payer assigned number authorizing the service(s).

Box Number: 24 Description: Used to list the completed services for the claim. The six service lines in section 24 have been divided horizontally to accommodate submission of both the NPI and another/proprietary identifier and to accommodate the submission of supplemental information to support the billed service. The top area of the six service lines is shaded and is the location for reporting supplemental information. It is not intended to allow the billing of 12 lines of service. The supplemental information is to be placed in the shaded section of 24A through 24G as defined in each Item Number. Providers must verify requirements for this supplemental information with the payer.

Box Number: 24a - Dates of Service Where this populates from: Appointment Date Description: Indicates the actual month, day, and year the service(s) was provided.

Box Number: 24b - Place of service Where this populates from: Locations & Rooms > Edit Location > Facility Code Description: Used to identify the location where the service was rendered. Enter the appropriate two-digit code from the Place of Service Code list for each item used or service performed.

Box Number: 24c - EMG Where this populates from: can not be modified within Unified Practice Description: Identifies if the service was an emergency. Check with payer to determine if this information (emergency indicator) is necessary. If required, enter Y for “YES” or leave blank if “NO” in the bottom, unshaded area of the field. The definition of emergency would be either defined by federal or state regulations or programs, payer contracts, or as defined in 5010A1.

Box Number: 24d - Procedures, services, or supplies Where this populates from: Appointment bill, CPT codes -or- CPT Fee Schedule [on iPad] Description: Used to identify the medical services and procedures provided to the patient. Enter the CPT code(s) and modifier(s) (if applicable) from the appropriate code set in effect on the date of service. This field accommodates the entry of up to four two-digit modifiers. The specific procedure code(s) must be shown without a narrative description.

Box Number: 24e - Diagnostic pointer Where this populates from: Appointment bill, CPT codes, ICD pointer -or- Chief Complaint & ICD [on iPad] Description: Used to indicate the line letter from Box 21 that relates to the reason the service(s) was performed. Enter the diagnosis code reference letter (pointer) as shown in Box 21 to relate the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow. The reference letter(s) should be A – L or multiple letters as applicable. ICD-9-CM (or ICD-10-CM, once mandated) diagnosis codes must be entered in Box 21 only. Do not enter them in 24e.

Box Number: 24f - Charges Where this populates from: Fee Schedule (or if changed, charge in billing info screen) Description: The total billed amount for each service line. Enter the charge for each listed service, right justified in the dollar area of the field. Do not use commas when reporting dollar amounts. Negative dollar amounts are not allowed. Dollar signs should not be entered. Enter 00 in cents area if the amount is a whole number.

Box Number: 24g - Days or Units Where this populates from: Appointment Billing Info Description: Used to indicate the number of days corresponding to the dates entered in 24A or units as defined in CPT coding manual(s). Enter the number of days or units. This field is most commonly used for multiple visits, units of supplies, anesthesia units or minutes, or oxygen volume. If only one service is performed, the numeral 1 must be entered. Enter numbers left justified in the field. No leading zeros are required. If reporting a fraction of a unit, use the decimal point.

Box Number: 24h - EPSDT Family Plan Where this populates from: cannot be modified within Unified Practice Description: Box 24h is used to identify certain services that may be covered under some state plans.

Box Number: 24i - ID Qualifier Where this populates from: cannot be modified within Unified Practice Description: Indicate the appropriate qualifier and identifying number in the shaded area.

Box Number: 24j - Rendering Provider ID# Where this populates from:  

Description: Indicates the individual performing/rendering the service.

Box Number: 25 - Federal TAX ID number

Where this populates from:   Account > My Account > Personal Tax ID > switch U se this ID as the Tax ID for my Superbills and Claim forms for billing toggle to Yes . 

• If Practitioner Tax ID is empty or Use this Tax ID… .. is turned off then it takes the Tax ID configured in Billing Information
• If both are empty, the field remains empty

Description: Indicates the unique identifier assigned by a federal or state agency. Enter the Federal Tax ID Number (employer ID number or SSN) of the Billing Provider identified in Box 33. This is the tax ID number intended to be used for 1099 reporting purposes. Enter an X in the appropriate box to indicate which number is being reported. Only one box can be marked.

Box Number: 26 - Patient Account Number Where this populates from: cannot be modified within Unified Practice Description: Indicates the identifier assigned by the provider.

Box Number: 27 - Accept Assignment? Where this populates from: Billing Info > Billing Preferences > Accept Assignment Description: Indicates that the provider agrees to accept assignment under the terms of the payer’s program. Enter an X in the correct box. Only one box can be marked. Report Accept Assignment? for all payers.

Box Number: 28 - Total Charge Where this populates from: Service balance due in Billing Info Description: Indicates the total billed amount for all services entered in Box 24f (lines 1–6). Enter total charges for the services (i.e., total of all charges in 24F). Enter the number right justified in the dollar area of the field. Do not use commas when reporting dollar amounts. Negative dollar amounts are not allowed. Dollar signs should not be entered. Enter 00 in cents area if the amount is a whole number.

Box Number: 29 - Amount Paid Where this populates from: Billing Info > Billing Preferences > switch Amount Paid - fill-in amount paid by patient for services to Yes and fill in the amount. This will auto-fill from payment received/applied. Description: Indicates the payment received from the patient or other payers. Enter total amount the patient and/or other payers paid on the covered services only. Enter the number right justified in the dollar area of the field. Do not use commas when reporting dollar amounts. Negative dollar amounts are not allowed. Dollar signs should not be entered. Enter 00 in cents area if the amount is a whole number.

Box Number: 30 - Balance Due Where this populates from: Total charge minus balance due that is listed on the CMS-1500 form.

Box Number: 31 - Signature of Physician or Supplier Where this populates from: Name in My Account & the Date of Service - or - Clinic Settings then Clinic Staff and click Details to the right to the Practitioner's name.

• The signature will reflect the name of the Practitioner assigned to the appointment - or - the last Practitioner to sign and lock the SOAP note.

Box Number: 32 - Service Facility Location Information Where this populates from: Clinic Settings > Locations & Rooms > Edit Location Description: Indicates the name and address of facility where services were rendered identifies the site where service(s) were provided. Enter the name, address, city, state, and ZIP code of the location where the services were rendered.

Box Number: 32a Where this populates from: Clinic Settings > Locations & Rooms > Edit Location > Service Facility NPI

• If this is not entered, 32a remains empty.  

Box Number: 32b Where this populates from: cannot be modified within Unified Practice Description: Indicates the non-NPI ID number of the service facility as assigned by the payer for the facility. Enter the 2-digit qualifier identifying the non-NPI number followed by the ID number. Do not enter a space, hyphen, or other separator between the qualifier and number.

Box Number: 33 - Billing Provider Info & Phone Number Where this populates from: Defaults from Business Information -or- If alternate pay to info is selected in My Account/Billing Information , will pull from there. Description: Box 33 is used to indicate the billing provider’s or supplier’s billing name, address, ZIP code, and phone number and is the billing office location and telephone number of the provider or supplier. Enter the provider’s or supplier’s billing name, address, ZIP code, and phone number. The phone number is to be entered in the area to the right of the field title. Enter the name and address information in the following format: 1st Line – Name 2nd Line – Address 3rd Line – City, State and ZIP Code Item 33 identifies the provider that is requesting to be paid for the services rendered and should always be completed. Do not use punctuation (i.e., commas, periods) or other symbols in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). Enter a space between town name and state code; do not include a comma. Report a 9-digit ZIP code, including the hyphen. Do not use a hyphen or space as a separator within the telephone number.

Box Number: 33a - Billing Information > Billing NPI Where this populates from: Clinic Settings > Clinic Staff > Details   -or- My Account if Use this NPI... is turned on .

• If this is turned off for the practitioner account page, this populates from Clinic Settings > Billing information . 
• If both are empty, 33a remains empty. 

Description: Indicates the HIPAA National Provider Identifier number. Enter the NPI number of the billing provider in 33a.

Where this populates from: Billing Info > Billing Preferences > G roup ID Description: Indicates the payer-assigned unique identifier of the professional.

As a Medical Biller, the better you understand the medical insurance payment process, the better you can care for your patients. Your understanding of what a patient will owe and what will be covered can help them navigate the confusing world of medical insurance.

One term that can be very confusing for patients (and for doctors as well) is ‘Accepting Assignment’.

Essentially, ‘assignment’ means that a doctor, (also known as provider or supplier) agrees (or is required by law) to accept a Medicare-approved amount as full payment for covered services.

This amount may be lower or higher than an individual’s insurance amount, but will be on par with Medicare fees for the services.

If a doctor participates with an insurance carrier, they have a contract and agree that the provider will accept the allowed amount, then the provider would check “yes”.  

If they do not participate and do not wish to accept what the insurance carrier allows, they would check “no”.   It is important to note that a provider who does not participate can still opt to accept assignment on just a particular claim by checking the “yes” box just for those services.

In other words by saying your office will accept assignment, you are agreeing to the payment amount being covered by the insurer, or medicare, and the patient has no responsibility.

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Claim Forms: Accept Assignment - Box 27

Box 27 is used to indicate that the provider agrees to accept assignment under the terms of the payer’s program.

By default, when you create a claim in Healthie, YES is selected for the claim. 

There is a known error related to Office Ally direct integration that may be related to Box 27. Please review the Office Ally troubleshooting article here . 

Forthcoming Updates

There is a planned update that will allow provider's to select Accept Assignment. We will update this article when it goes live. 

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