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Is My Provider Approved by Medicare?

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Medicare spending was $705.9 billion in 2017, according to the Centers for Medicare and Medicaid Services (CMS). Medicare providers are motivated to receive and maintain their Medicare certification in order to be eligible to receive some of this sizable sum as payment for their services.

To be approved or certified by Medicare means that the provider has met the requirements to receive Medicare payments.

Medicare certification is one way to protect you as the Medicare beneficiary and assure the quality of your care.

What is a Medicare provider?

A Medicare provider is a person, facility, or agency that Medicare will pay to provide care to Medicare beneficiaries. For example, a Medicare provider could be:

  • A home health agency
  • A hospital
  • A nursing home
  • A dialysis facility

The same Medicare provider may be covered by Original Medicare (Part A and Part B), Medicare Advantage, and Medicare Supplement.

What does it mean for a Medicare provider to be certified?

A Medicare provider becomes certified once they’ve passed inspection by a state government agency.

Medicare provider certification involves a lengthy application form. Once the Medicare provider is approved, they receive a National Provider Identifier (NPI) and Medicare billing number.

What if my provider is not approved?

Medicare only covers care from certified Medicare providers. If you receive a typically covered service from a non-certified provider, your care may not be covered.

If you wish to continue using that provider, you may have to pay all costs out of pocket.

Where can I find covered Medicare providers?

Medicare provides a tool to help you find Medicare providers and make comparisons about the care they provide.

Are all Medicare providers in-network?

If you have a Medicare Advantage plan, such as Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO) plan, it may use a network of Medicare providers in order to keep costs down. However, this network means that some Medicare-certified providers may be excluded from your coverage. You usually have an option to see out-of-network providers if you are willing to pay more.

If you stay with Original Medicare (Part A and Part B) you are not generally restricted by a provider network.

To look for Medicare plans and Medicare providers in your location, enter your zip code on this page.

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