Medicare Enrollment FAQ
Do I need to either enroll in Medicare or formally opt out?
If you provide Medicare Part B covered items and services you need to either enroll using form CMS-855I or formally opt out. If you’re not sure which items and services Medicare Part B covers in your area, see "How can I find out which dental items and services are covered by Medicare" below.
If you don’t provide Medicare Part B 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.
Dentists are not required to enroll or opt out in order for Medicare Part D prescription drug plans to cover the cost of prescriptions.
Note that with limited exceptions, a Medicare Part C (Medicare Advantage) plan will not reimburse a dentist who has opted out of Medicare, nor will the plan reimburse the patient (see FAQ below). Medicare Advantage Plans are a type of Medicare health plan offered by private companies. Such plans provide the Medicare beneficiary Part A and Part B benefits, and may also offer additional coverage such as dental, vision, or prescription drug coverage.
If I opt out of Medicare, can I continue to receive payment for services to Medicare beneficiaries under a Medicare Advantage plan?
No. If a dentist has opted out of Medicare, a Medicare Advantage plan will generally not pay the dentist or the patient. There is an exception for emergency or urgently needed services.
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.
How can I find out which dental items and services are covered by Medicare Part B?
Medicare Part B 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 Part B 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 (see FAQs above).
Dentists can ask their local Medicare contractors which items and services are covered by Medicare Part B. A state-by-state map on the CMS website provides contact information for all Medicare contractors.
I provide Medicare Part B covered items and services. How do I enroll in Medicare?
CMS Form 855i is used to enroll in Medicare in order to provide Part B covered items and services.
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.” There, the 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 Medicare Provider Enrollment, which provides information about the Medicare Provider Enrollment, Chain and Ownership System (PECOS), enrollment, revalidation, protecting your identity and privacy, providers who solely order or certify, and DMEPOS supplier requirements.
How do I opt out of Medicare?
To opt out of Medicare, a dentist must file an affidavit with each applicable Medicare contractor 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 Certify Items and Services to Medicare Beneficiaries (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.
If a dentist opts out of Medicare, then a Medicare Advantage Plan may not reimburse the dentist or the patient, except for emergency or urgent care services. A Medicare Advantage Plan is a type of Medicare health plan offered by a private company that contracts with Medicare to provide the patient with all of his or her Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations (“HMOs”), Preferred Provider Organizations (“PPOs”), Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. Some Medicare Advantage Plans also offer dental, vision, prescription drug coverage, and other coverage not covered by Original Medicare.
I don't provide Medicare Part B covered items or services, but I do order covered imaging, clinical laboratory, and DMEPOS. How do I enroll?
Dentists may use the simplified enrollment form CMS-855-O (PDF), which CMS developed for dentists and other health care professionals who wish to enroll only to order covered clinical laboratory services, imaging services, and DMEPOS for Medicare beneficiaries.
Additional information about enrolling only to order imaging, clinical laboratory and DMEPOS (and not to bill Medicare for covered services) is available at Medicare Provider Enrollment.
Note that dentists and other practitioners who enroll only to order imaging, clinical laboratory and DMEPOS cannot send claims to Medicare for providing Part B covered items and services. They do not have Medicare billing privileges for the purpose of submitting claims to Medicare for such services that they furnish to Medicare beneficiaries. See Medicare Provider Enrollment.
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 PECOS FAQs.
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 to order covered imaging services, clinical laboratory services, and DMEPOS?
No. According to CMS, your enrollment is valid and there is no need to re-enroll.
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 CMS, “Medicare Provider Enrollment” (scroll down to “Options to Verify Your Current Enrollment Record Exists in PECOS”).
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, or DMEPOS?
Medicare will deny the claim submitted by the imaging service, clinical lab, DMEPOS supplier.
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, and 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 CMS Medicare Provider Enrollment and PECOS FAQs.
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: “Claims for items or services ordered by interns and residents, whether licensed or unlicensed, must specify the NPI and name of a teaching physician. State-licensed residents may enroll to order or certify, and claims may list them. If States provide provisional licenses or otherwise permit residents to order or certify, CMS allows interns and residents to enroll, consistent with State law.” See CMS Medicare Provider Enrollment.
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. With respect to ordering covered clinical laboratory, imaging, and home health services, CMS has projected 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?
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 CMS Medicare Provider Enrollment.
I’ve heard that CMS will use site visits as a screening activity to make sure only qualified providers and suppliers are enrolled. If I enroll in Medicare, could I be subject to a site visit?
According to CMS, a dentist who enrolls only to order imaging, clinical laboratory and DMEPOS (i.e., using form CMS 855-O) will not be subject to such a site visit. However, a dentist who enrolls to bill Medicare for items or services covered by Part B (i.e., using form CMS 855-I) may receive such a site visit. In other words, the site visits are only performed on billing providers. Providers that are enrolled solely to order covered clinical laboratory services, imaging services, or DMEPOS are not subject to these visits.
The purpose of the site visit is to determine that the location identified by a provider on his or her application is open and operational. CMS will utilize its National Site Visit Contractor to perform these site visits. Results of the site visits are transmitted to CMS/MACs (Medicare Administrative Contractor) to take the appropriate action if the location is found to be non-operational (e.g., deactivation or revocation).
CMS announced in February, 2016 that increasing the number of such site visits is one of four tactics to reinforce screening activities aimed at protecting the integrity of the Medicare program and making sure only qualified providers and suppliers are enrolled. For more information, visit CMS, Strengthening Provider and Supplier Enrollment Screening.
CMS will deactivate the enrollment of providers who have not billed Medicare in the last 13 months. Does this apply to dentists?
Dentists should not be subject to deactivation for failure to bill, whether they enroll to bill Medicare (i.e., using form CMS 855-I) or just to order covered clinical laboratory services, imaging services, or DMEPOS (i.e., using form CMS 855-O).
According to CMS, the purpose of the deactivation process is to deactivate providers who have not billed Medicare in a specified period of time but who may have failed to notify Medicare that they are no longer practicing or participating with Medicare. CMS will conduct an analysis before taking any action to deactivate a provider who hasn’t billed in 13 months. Specifically CMS checks whether the provider is enrolled solely to order covered clinical laboratory services, imaging services, or DMEPOS, and checks on certain specialty types, e.g. pediatricians, dentists and mass immunizers (roster billers). These providers will be excluded from the deactivation actions. In addition, any provider deactivated will receive notification of this action from their Medicare Administrative Contractor (“MAC”).
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Revised February 6, 2020