Find In-Network Medicare Providers & Pharmacies (2024)

FAQs

Who is considered as a provider by Medicare? ›

A Medicare provider is a facility, supplier, physician, or other individual or organization that furnishes health care services. Under Medicaid, a provider is an individual, group, or agency that provides a covered Medicaid service to a Medicaid enrollee.

Centers for Medicare & Medicaid Services (CMS) provides information about Medicare coverage, Medicare health plans, Medicare quality initiatives and free publications. The Medicare Helpline: 1-800-MEDICARE (1-800-633-4227) TTY: 1-877-486-2048. Find your state Medical Assistance Office.

Any organization, institution, or individual that provides health care services to Medicare beneficiaries. Physicians, ambulatory surgical centers, and outpatient clinics are some of the providers of services covered under Medicare Part B. A doctor, hospital, health care professional, or health care facility.

Visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227) to get the most current information. TTY users can call 1-877-486-2048. “Choosing a Hospital” isn't a legal document. Official Medicare Program legal guidance is contained in the relevant statutes, regulations, and rulings.

Provider & Supplier Resources

- Section of the CMS.gov website that is designed to provide Medicare enrollment information for providers, physicians, non-physician practitioners, and other suppliers. - Check to see if you have been sent a notice to revalidate your information on file with Medicare.

Under federal regulations, a "health care provider" is defined as: a doctor of medicine or osteopathy, podiatrist, dentist, chiropractor, clinical psychologist, optometrist, nurse practitioner, nurse-midwife, or a clinical social worker who is authorized to practice by the State and performing within the scope of their ...

Plans C and F.

Plan F has been the most popular because of its generous benefits. It covers the Medicare Part A hospital deductible and co-payments, the Part B deductible, and some emergency care outside the U.S.

AARP's Medicare Question and Answer Tool offers practical and comprehensive information to help you navigate the program according to your own situation.

In some cases, you'll have a higher share of costs when you see an out-of-network doctor. In other cases, you're not covered at all if you go out of network. This is particularly important if you travel a lot because Medicare Advantage plans generally don't provide out-of-state coverage.

Non-participating providers accept Medicare but do not agree to take assignment in all cases (they may on a case-by-case basis). This means that while non-participating providers have signed up to accept Medicare insurance, they do not accept Medicare's approved amount for health care services as full payment.

Does Medicare require a referring provider? ›

There are three basic requirements for order/referring Medicare beneficiaries: The provider must be enrolled in Medicare in an approved or an opt-out status. The NPI must be for an individual provider, not an organizational NPI. The provider must be of a specialty type that is eligible to order and refer.

To learn about Medicare, see the “Introduction to Medicare” fact sheet. You can also visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227); TTY users should call 1-877-486-2048.

Healthcare organizations that achieve Medicare certification through a Joint Commission "deemed status" accreditation survey are determined to meet or exceed Medicare and Medicaid requirements.

Detailed information about Medicare claims data can be found at the Research Data Assistance Center (ResDAC), which contracts with CMS to support research using CMS data. They have extensive online documentation and a very helpful help desk.

The term “health care provider” includes a hospital, skilled nursing facility, nursing facility, home health entity or other long term care facility, health care clinic, community mental health center (as defined in section 300x–2(b)(1) of this title), renal dialysis facility, blood center, ambulatory surgical center ...

Supplier means a physician or other practitioner, or an entity other than a provider, that furnishes health care services under Medicare.

Participating providers accept Medicare and always take assignment. Taking assignment means that the provider accepts Medicare's approved amount for health care services as full payment. These providers are required to submit a bill (file a claim) to Medicare for care you receive.

Non-participating providers, sometimes referred to as “out-of-network” providers, do not have formal contracts with any particular insurance network, in contrast to participating providers. Rather, they are autonomous entities that set their own prices for healthcare services.