Form CMS-460 at a glance
What it is: Form CMS-460 (12/28), the Medicare Participating Physician or Supplier Agreement, is an agreement with the Medicare program to accept assignment of the Medicare Part B payment for all eligible services.
Where and when to file: Do not send your CMS-460 form to CMS, send it to your MAC; if you send your forms to CMS, it will delay processing of your CMS-460 forms.
A filled-in Form CMS-460 example: a new physician signs the agreement
How to fill out Form CMS-460, box by box
Participant names and the NPI
In Name(s) and Address of Participant and National Provider Identifier (NPI), list all names and the NPI under which the participant files claims with the Medicare Administrative Contractor (MAC) with whom this agreement is being filed.
Box 2, Effective Date
A new physician, practitioner or supplier can sign the participation agreement at the time of enrollment into the Medicare Program, and the agreement becomes effective on the date of filing, the date the participant mails (post-mark date) the agreement to the MAC or delivers it to the MAC.
If the participant files the agreement with any MAC during the enrollment period, the agreement becomes effective on the date written in Box 2.
Signature of participant, Date, Title and Office Phone Number
Sign on the Signature of participant line (or as authorized representative of participating organization) and enter the Date.
If the signer is an authorized representative of the organization, enter the Title; enter the Office Phone Number including the area code.
Received by, Initials of MAC Official and Effective Date
The form has the lines Received by (name of MAC), Initials of MAC Official and Effective Date.
More rules for Form CMS-460
Accepting assignment of the Medicare Part B payment means requesting direct Part B payment from the Medicare program, and the participant shall not collect from the beneficiary or other person or organization for covered services more than the applicable deductible and coinsurance.
If you bill for physicians' professional services, your Medicare fee schedule amounts are 5 percent higher if you participate.
If your situation is different
You are a new physician, practitioner or supplier
If you are a new physician, practitioner or supplier and you choose to be a participant, complete the blank agreement (CMS-460) and submit it with your Medicare enrollment application to your MAC.
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 participate within this 90-day timeframe, complete the CMS-460 and send to your MAC.
You are not currently a Medicare participant
What to do during open enrollment: if you choose to be a participant and you are not currently a Medicare participant, complete the blank agreement (CMS-460) and mail it (or a copy) to each MAC to which you submit Part B claims, showing the name(s) and identification number(s) under which you bill.
When the decision to participate can be made: toward the end of each calendar year, all MAC have an open enrollment period, which generally is from mid-November through December 31.
You decide not to participate and you are currently a participant
If you decide not to participate and you are currently a participant, write to each MAC 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.
Common questions about Form CMS-460
Is there a penalty?
Civil and criminal penalties may also be imposed for violation of the agreement.
Sources
[1] Form CMS-460 (12/28), Medicare Participating Physician or Supplier Agreement, Centers for Medicare & Medicaid Services (the Official source link on this page).