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Printed Date: 9/22/2015
How To Complete a Medicare Participating Physician or Supplier Agreement (CMS-460)
Upon receipt of a new Medicare provider number, a new Medicare provider entity has 90 days to submit to the Medicare carrier or A/B MAC a signed Medicare Participating Physician or Supplier Agreement (CMS-460). A participating provider enters into an agreement to accept the Medicare-approved amount as full payment for services and supplies covered under Part B. This agreement (CMS-460) renews automatically each year. Exception: A change in name and/or EIN (tax identification number) is a change in identity and requires a new participation decision. A participating provider receives five percent more on reimbursement for physician related services. Those who have not signed a participation agreement are listed as non-participating providers and are subject to the limiting charge fee schedule. The Medicare Participating Physician or Supplier Agreement (CMS-460) is available by clicking on the link below. Complete and mail the signed form to Palmetto GBA. The participation agreement is completed as follows:
Name(s) and Address of Participant
Type or print the name and address of the new provider entity under which you will be receiving Medicare reimbursement.
Physician or Supplier Identification Code(s)
Indicate your new Medicare number (PTAN). If your new provider number is pending, enter your tax identification or social security number.
Enter the date the CMS-460 is being delivered or being mailed to the Medicare carrier or A/B MAC. Beginning of Agreement is the date you are mailing your participation agreement to the Medicare carrier or A/B MAC.
Signature of Participant or Authorized Representative of Participating Organization
This section needs a provider's signature or authorized representative.
This section needs the title of provider (M.D., etc.) or representative.
This section needs the date the agreement is signed.
Office Phone Number
This section needs the phone number of the practice.
Received By, Effective Date, Initials of Carrier Official
This section is completed by the Medicare carrier or A/B MAC.
Send completed forms to:
JJ Part BJM Part B
Part B Palmetto GBA
P.O. Box 100306
Columbia, SC 29202-3306
Part B Palmetto GBA
Mail Code: AG-310
P.O. Box 100190
Columbia, SC 29202-3190
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Last Updated: 02/14/2018