Medicare Enrollment FAQ
Do I need to either enroll in Medicare or formally opt out?
If you provide Medicare covered items and services you need to either enroll using form CMS-855I or formally opt out.
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.
As of June 1, 2016, Medicare Part D plans will not cover prescription drugs unless the prescribing dentist is enrolled or opted out. Dentists should allow sufficient processing time to avoid prescription drug claims from being denied by Part D plans when this requirement takes effect. For more information on the Part D enrollment/opt out requirement, see the CMS publication Provider Enrollment Requirements for Writing Prescriptions for Medicare Part D Drugs.
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.
How can I find out which dental items and services are covered by Medicare?
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.
I provide Medicare covered items and services. How do I enroll in Medicare?
How do I opt out of Medicare?
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.
I don't provide Medicare covered items or services, but I do order covered imaging, clinical laboratory, DMEPOS and prescribe drugs for patients with Medicare Part D prescription drug plans. How do I enroll?
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.
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.
What is "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?
I'm not sure whether I'm enrolled in Medicare. Is there a way to check?
You can look up your name in the Centers for Medicare & Medicaid (“CMS”) Order and Referring data file. The data file has the first name, last name, and National Provider Identifier (“NPI”) number for all doctors and non-physician practitioners who are legally eligible to order and refer in the Medicare program and who have enrollment records in PECOS. You can access the database here.
For more information see page 4 of the CMS fact sheet Medicare Enrollment Guidelines for Ordering/Referring Providers (PDF).
What if I enroll in Medicare using CMS-855-O, but later wish to enroll to be reimbursed by Medicare?
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, 2016, Medicare Part D will not cover prescriptions from dentists who are not enrolled or opted out.
I bill Medicare for imaging services, clinical laboratory services, or DMEPOS. What do I need to do?
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).
Which NPI needs to be on the claim: Type I or Type II?
Type I (individual) NPIs must be on the claim forms, not Type II (organizational) NPIs.
How long will it take for my CMS-855-O to be processed?
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.
What if the information on my enrollment application changes?
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).
What are the recordkeeping requirements for dentists who order covered clinical laboratory services, imaging services, or DMEPOS?
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.
What about orders from residents?
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).
What is the purpose of this regulation?
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.
How can I protect my information in PECOS from identity thieves and persons who want to commit fraud?
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, 2015 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 October 1, 2015