Payment for Services Rendered On or After April 1, 1994, by

150.1 - Payment for Services Rendered On or After April 1, 1994, by Noncontracted Medicare Participating Physicians (Rev. 4, 10-01-01) The limit of the HMO/CMP’s liability for services rendered by a physician with whom it does not contract depends on whether the physician is a Medicare participating physician (i.e., has agreed to accept assignment on all Medicare claims submitted to Medicare). The Medicare participation agreement is deemed to apply to such a physician’s services in the sense that the physician may not bill the HMO/CMP, the beneficiary, or any other party for any amount in excess of the Medicare allowed amount (the fee schedule amount or the actual charge, if lower). However, the HMO/CMP has financial responsibility for the amount that would have been the beneficiary’s liability in FFS Medicare (the 20 percent coinsurance and any unmet deductible). NOTE: The financial responsibility of the HMO/CMP applies only when the services are covered by the HMO/CMP, i.e., for emergency or urgently needed services or when the HMO/CMP refers the enrollee to the non- network physician.