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'Specialist services' excluded from Medicare final rule

July 18, 2012

By Craig Palmer, ADA News staff

Washington—Dentists and other health care providers ordering particular Medicare-covered items or services for Medicare beneficiaries will be required to enroll in the government insurance program under a final rule issued June 26, 2012 by the Department of Health and Human Services.

However, dentist referrals to specialists are not covered by the rule, and referral to a specialist would not require the referring dentist to enroll in Medicare. The specialist could submit a Medicare claim without having to list the referring dentist.

“Based upon review of the public comments received, we have decided to remove specialist services from the requirements of this rule,” the HHS Centers for Medicare & Medicaid Services said. “In this final rule we specifically designate the covered items and services as follows: DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics and Supplies) items, clinical laboratory, imaging and home health services.”

The Affordable Care Act requires that physicians, dentists and other providers who order or certify certain items or services be enrolled in Medicare. “This rule implements the statutory requirement that individuals who order and certify particular Medicare-covered services be enrolled in the Medicare program,” the regulation said. ““¦in order for a claim to be paid, the ordering physician/practitioner must be enrolled in Medicare in an approved status or must have validly opted-out of the Medicare program.”

A dentist can enroll in Medicare as a provider of covered services or use a simplified form to enroll only for ordering/referring purposes. A dentist who is not enrolled in Medicare as a provider of covered services cannot bill Medicare. A dentist who has opted out of Medicare is not required to enroll to order or certify Medicare-covered items or services.

Eligible Professionals

The final rule cites as examples of eligible professionals who may wish to enroll in Medicare only to order and certify and not to submit claims to Medicare for payments those who are:

  • employed by the Public Health Service, Department of Defense and Department of Veterans Affairs;
  • employed by Medicare-enrolled federally qualified health centers (FQHCs), rural health clinics (RHCs) and critical access hospitals (CAHs);
  • pediatricians who traditionally have very few Medicare patients and, therefore, only order or certify items for Medicare beneficiaries;
  • doctors of dental medicine or dental surgery whose services are generally not covered by Medicare, and
  • residents including interns and fellows who are appointed by teaching hospitals and academic medical centers who generally do not enroll in Medicare because their services are not directly billed to Medicare; the term “resident” is defined to include programs in osteopathy, dentistry and podiatry.

Simplified Enrollment

The Association recommended a simplified enrollment process for dentists who want to enroll in Medicare solely for ordering and referring covered items and services, which Medicare approved. The abbreviated process does not apply to dentists already enrolled to provide Medicare services or enrolling for the purpose of submitting claims.

“We have created a streamlined application process that reduces the time it will take for dentists and other professionals to enroll, since they generally do not bill Medicare but who need to enroll in Medicare just to order and certify,” HHS said in the final rule. “The CMS 855O may be used by providers and suppliers who simply wish to order and certify and do not wish to submit claims to Medicare.

“These changes, including the new CMS-855O enrollment form, the change from the (interim rule) requirement to be enrolled in PECOS (Provider Enrollment, Chain and Ownership System) to a requirement to be enrolled in Medicare, and the delay in the activation of the automated edits that would cause a claim to not be paid due to lack of an approved enrollment record in Medicare, have simplified compliance for these types of professionals,” the regulatory notice said.

Although the final rule expands the enrollment requirement “to one requiring enrollment in Medicare, which includes enrollment in PECOS or the local legacy (claims payment) systems, our requirements have not practically changed,” HHS said. “In addition, we are continuing to make major revisions to the enrollment process that will significantly reduce delays and other problems associated with PECOS enrollment.”

Claims rejection on the basis of this regulation has not begun. Providers will have at least 60-day notice before application of automated edits that would cause a claim not to be paid due to lack of an approved enrollment record in Medicare for the ordering or certifying physician, dentist or other eligible health professional, HHS said. The edits will apply to only those claims with a date or service on or after the date the edits are automated.

Keeping Dentists Informed

HHS “understand(s) there has been some confusion in the past” that resulted in returned enrollment applications and acknowledges “some errors” of omission of some eligible professionals from the Ordering Referring Reports available on the Medicare provider/supplier enrollment website. Medicare contractors have been instructed to process the applications at issue and “we have corrected the errors,” the notice said.

HHS said it will increase professional and public outreach and education on the regulation.

“We will also continue to provide information directly to the ADA (American Dental Association), DoD (Department of Defense), DVA (Department of Veterans Affairs), PHS (Public Health Service) and other affected employers of physicians and other eligible professionals who enroll in Medicare just to order and certify.”

The Association had also recommended that HHS exclude dental laboratories from the May 5, 2010 interim final rule definition of “laboratory” and exempt certain dentists from the regulation’s document retention and disclosure requirements.

“We do not believe that dental laboratories should be excluded from the requirements of this final rule,” HHS responded. “We decline to define dental laboratories in this final rule; however, dental laboratories are, in fact, laboratories. These laboratories, from time to time, provide covered services under the limited circumstances in which dental services are covered by Medicare.”

“Dentists and others who will be enrolling only to order should be fully aware of the documentation retention and disclosure requirements beforehand,” HHS said. “We have already published considerable information about these requirements and have communicated directly and in numerous open door forums about these requirements. We will publish additional guidance, as appropriate, via a Medicare Learning Network product, messages in our provider/supplier listservs and presentations at our provider/supplier open door forums.”

HHS also offers information in the Medicare Learning Network provider-supplier enrollment fact sheet series. Information about enrolling only to order and certify is available on the Medicare provider/supplier enrollment website (

The ADA offers Medicare contract, opt-out and other member information at and will continue to update the Medicare regulatory information in Association online and print media. Medicare does not cover most routine dental services and the program will not pay for non-covered services. Medicare Part A provides benefits for certain in-hospital services and Part B provides benefits for certain doctors’ services, hospital outpatient services and home health care.

Dentists may elect to opt out of the Medicare program and provide Medicare-covered services by entering into written “Private Contracts” with their Medicare-eligible (generally, senior and disabled) patients and by filing an Affidavit with each applicable Medicare carrier.

HHS indicates that patients may well be confused by the changes. “We recognize that this requirement may pose issues for beneficiaries who need care and who are unsure whether their physician is enrolled in Medicare,” the notice said. “There are a number of ways a beneficiary can determine whether a physician is actually enrolled in Medicare, including to ask the physician whether he or she is enrolled.”

Medicare defines “physician” to include dentists.