If you don’t provide Medicare covered items and services, but you order covered clinical laboratory services, imaging services, or DMEPOS for patients who are on Medicare, you need to either enroll or formally opt out. You can enroll using a shorter enrollment form called CMS-855-O. By June 1, 2015 February 1, 2017, if you are not enrolled or opted out, Medicare will not reimburse prescription drugs you prescribe for a patient with a Medicare Part D prescription drug plan.
If you’re not sure which items and services Medicare covers in your area, see “How can I find out which dental items and services are covered by Medicare” below.
This handy flow chart prepared by the ADA will walk you through the decision making process. Download the flow chart by clicking here.
Medicare generally does not cover routine dental items and services. See Centers for Medicare & Medicaid Services “Medicare Dental Coverage.”
A narrow exception permits coverage of certain dental services that are necessary to the provision of certain Medicare covered medical services.
Medicare may also cover certain medical procedures that dentists are licensed to perform (for example, a biopsy for oral cancer).
In addition, certain dental items and services, such as dental sleep apnea devices, may be covered in certain geographic areas through local coverage determinations, provided specific requirements are met.
Medicare Advantage Plans provide Medicare-covered benefits to members, and sometimes offer extra benefits that original Medicare doesn’t cover, such as dental services.
Dentists can ask their local Medicare contractors which items and services are covered. A state-by-state map on the CMS website provides contact information for all Medicare contractors.
According to the Center for Medicare and Medicaid Services (“CMS”), “Physicians, non-physician practitioners, and other Part B suppliers must enroll in the Medicare Program to get paid for the covered services they furnish to Medicare beneficiaries. Enrolling in Medicare authorizes you to bill and receive payment for the covered services you furnish to Medicare beneficiaries.” The Medicare definition of “physician” includes dentists.
For information about enrolling in Medicare, visit CMS, Medicare Provider-Supplier Enrollment.
Information about enrollment is also available in Fact Sheets from the Medicare Learning Network entitled The Basics of Internet-based Provider Enrollment, Chain and Ownership System (PECOS) for Provider and Supplier Organizations (PDF), Internet-based PECOS FAQs (PDF), and The Basics of Medicare Enrollment for Physicians and Other Part B Suppliers (PDF).
To opt out of Medicare, a dentist must file an affidavit with each applicable Medicare carrier and enter into written “Private Contracts” with patients who are Medicare beneficiaries. Opting out requires specific compliance requirements, including rules for documentation and deadlines, that must be understood prior to deciding whether or not to opt out.
Information about opting out of Medicare is available in Chapter 15, Section 40 of the CMS Medicare Benefits Policy Manual. Information is also available in the CMS publication Opting Out of Medicare and/or Electing to Order and Refer Services (PDF). The ADA resource Opting Out of the Medicare Program contains a general discussion of the opt-out procedure. Medicare Opt-Out FAQ answers some additional questions about opting out.
Medicare has contracted with Wisconsin Physician Services to handle the enrollment of Indiana dentists for opting in and opting out. Click on the below link and select Medicare Opt Out Affidavit at the bottom of the same page.
After filling in the boxes, print, sign and mail the form to the address at this link.
To see a listing of Indiana dentists who have currently opted out of Medicare, click on this link and see specialty fields #19 and #85.
If you have further questions, please contact Ed Rosenbaum at (800) 562-5646 or firstname.lastname@example.org.
No. The affidavit that you must sign in order to opt out must state that, during the opt-out period, you understand that you may receive no direct or indirect Medicare payment for services that you furnish to Medicare beneficiaries with whom you have privately contracted, whether as an individual, an employee of an organization, a partner in a partnership, under a reassignment of benefits, or as payment for a service furnished to a Medicare beneficiary under a Medicare Advantage plan.
Once you file an affidavit notifying the Medicare carrier that you have opted out of Medicare, you are out of Medicare for twoyears from the date the affidavit is signed, unless you terminate the opt-out early under §40.35 of the Medicare Benefit Policy Manual (PDF), or unless you fail to maintain opt-out (see §40.11 of the Medicare Benefit Policy Manual [PDF]). After those two years are over, you could elect to return to Medicare or to opt out again.
Maybe. Under §40.35 of the Medicare Benefit Policy Manual (PDF), if you change your mind after the carrier has approved your opt-out affidavit, the opt-out may be terminated within 90 days of the effective date of the affidavit. To properly terminate an opt-out, you must:
If you were previously enrolled in Medicare, when you properly terminate opt-out in accordance with the second bullet above you will be reinstated in Medicare as if there had been no opt-out.
CMS has developed a simplified enrollment form CMS-855-O (PDF) for dentists and other health care professionals who wish to enroll only in order and prescribe for Medicare beneficiaries.
Medicare has contracted with Wisconsin Physician Services to handle the enrollment of Indiana dentists for opting in and opting out. Click on the below link and select Form 885O in the middle of the page to opt in.
After filling in the boxes, print, sign and mail the form to the address at this link.
Additional information about enrolling only to order and prescribe (and not to bill Medicare for covered services) is available in the CMS fact sheet Medicare Enrollment Guidelines for Ordering/Referring Providers (PDF).
Note that dentists and other practitioners who complete Form CMS-855-O cannot send claims to Medicare for providing covered items and services. They do not have Medicare billing privileges for the purpose of submitting claims to Medicare for services that they furnish to Medicare beneficiaries. See the CMS fact sheet Medicare Enrollment Guidelines for Ordering/Referring Providers(PDF).
Form CMS-855-O is available in hard copy format and there is an electronic version on PECOS.
PECOS is Medicare’s Internet-based “Provider Enrollment, Chain and Ownership System” that permits healthcare providers to enroll online. For information about using PECOS to enroll in Medicare, see Internet-based PECOS FAQs (PDF). I enrolled in Medicare using Form CMS-855-I, but I don’t provide Medicare covered services. Do I need to re-enroll using Form CMS-855-O in order to order covered imaging services, clinical laboratory services, and DMEPOS, or to prescribe drugs for patients with Medicare Part D prescription drug plans?
No. According to CMS, your enrollment is valid and there is no need to re-enroll. See the CMS fact sheet Medicare Enrollment Guidelines for Ordering/Referring Providers (PDF).
There are four options for verifying whether an enrollment record exists in PECOS. They are listed on page 4 of the CMS fact sheet Medicare Enrollment Guidelines for Ordering/Referring Providers (PDF).
You can convert an existing CMS-855-O enrollment application into a CMS-855-I enrollment application. See the CMS publication Converting a CMS-855O to a CMS-855I Enrollment: How To Guide (PDF). What happens if someone who isn’t enrolled or opted out orders covered imaging services, clinical laboratory services, DMEPOS, or prescribes Medicare Part D drugs?
Medicare will deny the claim submitted by the imaging service, clinical lab, DMEPOS supplier. After June 1, 2015, Medicare Part D will not cover prescriptions from dentists who are not enrolled or opted out.
To receive payment, the item or service must have been ordered by a doctor or practitioner eligible to order that item or service. The claim form must contain the legal name and National Provider Identifier (NPI) of the ordering doctor or practitioner. The ordering doctor or practitioner must be identified by his or her legal name and NPI, must be enrolled in Medicare in an approved status or have validly opted out of Medicare. Special rules apply when unlicensed residents, non-enrolled licensed residents, and license residents order/certify these items and services (see below).
Type I (individual) NPIs must be on the claim forms, not Type II (organizational) NPIs.
CMS has stated:
It is possible that it could take 45-60 days, sometimes longer, for Medicare enrollment contractors to process enrollment applications. All enrollment applications, including those submitted over the web, require verification of the information reported. Sometimes, Medicare enrollment contractors may request additional information in order to process the enrollment application.
CMS requires enrolled dentists to keep their information up to date. According to CMS: “You can submit a change of information using Internet-based PECOS or the paper enrollment application. You must report a change of ownership or control including changes in authorized official(s) or delegated official(s), changes in final adverse legal actions, and any revocation or suspension of a Federal or State license within 30 days of a reportable event. Submit all other changes within 90 days of a reportable event.” See the CMS fact sheet Medicare Enrollment Guidelines for Ordering/Referring Providers (PDF) and Internet-based PECOS FAQs (PDF).
Ordering dentists must maintain documentation for 7 years from the date of service and make the documentation available to CMS or a Medicare contractor upon request. The documentation includes written and electronic documents including the NPI of the ordering practitioner relating to written orders and requests for payments for items of DMEPOS and clinical laboratory, and imaging services.
According to CMS: “For claims for items or services ordered/referred by interns and residents, the claims must specify the name and NPI of a teaching physician. State-licensed residents may enroll to order/refer and claims may list them. Claims for covered items and services from unlicensed interns and residents must still specify the name and NPI of the teaching physician. However, if States provide provisional licenses or otherwise permit residents to order/refer services, CMS allows interns and residents to enroll to order/refer, consistent with State law.” See the CMS fact sheet Medicare Enrollment Guidelines for Ordering/Referring Providers (PDF).
CMS has identified vulnerabilities in Medicare enrollment procedures that have permitted the enrollment of providers whose qualifications for meeting enrollment standards were sometimes questionable, raising concerns that some of them may be under qualified or even fraudulent. CMS projects that the new requirements will save the Federal Government more than $100 million per year for ten fiscal years, and estimates that total savings after ten years will amount to $1.59 billion.
CMS requires users to change their passwords every 60 days, and encourages users to take the certain additional actions to help protect their Medicare enrollment information. See Safeguard Your Identity and Privacy Using PECOS (PDF).
The foregoing was prepared by the ADA Division of Legal Affairs. Its purpose is to promote awareness of legal issues that may affect dentists and dental practices. This document is not intended to provide either legal or professional advice, and cannot address every federal, state, and local law that could affect a dentist or dental practice. Because the law varies from jurisdiction to jurisdiction, and sometimes changes more rapidly than these materials, we make no representations or warranties of any kind about the completeness, accuracy, or any other quality of the information in the above piece. Nothing here represents advice or opinion as to any particular situation you may be facing; for that, it is necessary to consult directly with a properly qualified professional or with an attorney admitted to practice in your jurisdiction for appropriate legal or professional advice.To the extent the above includes links to any websites, the ADA intends no endorsement of their content and implies no affiliation with the organizations that provide their content. Nor does the ADA make any representations or warranties about the information provided on those sites, which we do not control in any way.© 2012, 2013, 2014 American Dental Association. All rights reserved. Reproduction of this material by member dentists and their staff for use in the dental office is permitted. Any other use, duplication or distribution by any other party requires the prior written approval of the American Dental Association.
Revised Sept. 25, 2014