What Is the Medicare-Approved Amount?
Short answer
The Medicare-approved amount is the amount Original Medicare recognizes for a covered service or item and uses as the basis for Medicare payment and applicable beneficiary cost sharing.
Coverage
When a provider accepts assignment, the approved amount is accepted as full payment for the covered service apart from deductible and coinsurance.
Not Automatic
The Medicare-approved amount can differ from a provider’s list price or usual charge and does not itself establish that a service is covered.
Costs And Ma
Nonparticipating providers may have different payment and limiting-charge rules. Medicare Advantage uses plan-negotiated network/payment structures rather than Original Medicare assignment rules.
Practical Example
A physician might list a higher charge, but if assignment is accepted, beneficiary cost sharing is calculated from Medicare’s approved amount rather than the list price.
Questions to verify
- Was the service covered?
- Did the provider accept assignment?
- Is this Original Medicare or a Medicare Advantage claim?