The facts and FAQ on Medicare

On April 16, 2018, the Centers for Medicare and Medicaid Services (CMS) published a final rule that revises Medicare Advantage program (Part C) regulations and Prescription Drug Benefit program (Part D) regulations, and implements certain provisions of the Comprehensive Addiction and Recovery Act.

Among other things, the new rule rescinds a proposal that would have required dentists who provide dental care and prescriptions for Medicare Advantage patients and Part D beneficiaries to be enrolled in Medicare, or to have opted out in order for their services to be covered. 

Additional questions may be directed to the American Dental Association at dentalbenefits@ada.org.

General Medicare questions

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-855-I (PDF) or formally opt out. 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.

If you don’t provide Medicare covered items and services, but you order covered clinical laboratory services, imaging services, or durable medical equipment, prosthetics, orthotics, and supplies (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 (PDF).

Dentists will not be required to enroll or opt out in order for Medicare Part D prescription drug plans to cover the cost of prescriptions.

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.

If I decide to enroll under either form CMS-855-I or CMS-855-O, or to opt out, where do I send my completed form or affidavit?

You must send the form or affidavit to each applicable Medicare Administrative Contractor (MAC) that services the state(s) where you practice. CMS has made available a list of MACs by state (PDF). You’ll need to send it to every Part B entity listed in the state(s) where you practice. Please remember that you are looking for the Part B (physician and non-physician provider) addresses, not Part A. You can also enroll (but not opt out) online using the Medicare Provider Enrollment, Chain, and Ownership System (PECOS).

When attempting to complete an enrollment form, I could not identify myself as a dentist. What box do I check?

The enrollment form lists two options appropriate for dentists: maxillofacial surgery and oral surgery (dentist only). Oral and maxillofacial surgeons may use the maxillofacial surgery category while all other dentists should use the oral surgery (dentist only) category.

Isn’t Medicare pretty much the same as Medicaid?

No. Medicare is the federal health insurance program for individuals 65 or older, younger individuals with certain disabilities, and individuals with end-stage renal disease. Medicaid is a joint federal and state program for individuals and families with limited income and resources.

The information on whether to enroll, opt out or do nothing offered in these questions and answers relates only to Medicare.

What is Medicare Advantage?

Medicare Advantage Plans provide Medicare-covered benefits to members, and sometimes offer extra benefits that original Medicare doesn't cover, such as dental services. If you opt out of Medicare, you may not receive reimbursement from a Medicare Advantage plan.

What is PECOS?

PECOS is Medicare's Internet-based “Provider Enrollment, Chain and Ownership System,” which permits healthcare providers to enroll online. For information about using PECOS to enroll in Medicare, see the CMS PECOS FAQs (PDF).

What if I supply durable medical equipment (DME) such as oral sleep apnea devices?

A dentist who wishes to receive reimbursement from Medicare for supplying oral sleep apnea devices must enroll as a DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies) supplier using form CMS-855-S (PDF). By itself, enrolling as a DMEPOS supplier does not satisfy the requirement for other Medicare-related actions, so a dentist must decide on additional enrollment using form CMS-855-I or CMS-855-O, opting out or doing nothing for other covered services.

What are the recordkeeping requirements for dentists who order covered clinical laboratory services, imaging services, or DMEPOS?

Ordering dentists must maintain documentation for seven years from the date of service, and make the documentation available to CMS or a MAC upon request. Documentation includes written and electronic documents, including the NPI of the ordering practitioner relating to written orders, as well as requests for payments for items of DMEPOS and clinical laboratory and imaging services.

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 CMS “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 Administrative Contractor (MAC) which items and services are covered. A state-by-state map on the CMS website provides contact information for all MACs.

General fee schedule information by location can be found on the CMS website under Fee Schedules—General Information.

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) using or just to order and prescribe (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 that the provider is enrolled solely to order, refer, and prescribe or 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 MAC.

Do I need an NPI to either enroll or opt-out?

You must have a National Provider Identifier (NPI), which you likely already have. If not, you may download and print an NPI enrollment form (PDF) or you may file the form online.

How can I protect my information in PECOS from identity thieves and persons who seek 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 the CMS fact sheet Safeguard Your Identity and Privacy Using PECOS (PDF).

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 (i.e., using form CMS 855-I) may be receive such a site visit. In other words, the site visits are only performed on billing providers. Providers that are enrolled solely to order and prescribe 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/MAC 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.

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 happens if I choose not to do anything?

Dentists will not be required to enroll or opt out in order for Medicare Part D prescription drug plans to cover the cost of prescriptions.

If you provide Medicare covered items and services you need to either enroll using form CMS-855-I (PDF) or formally opt out. If you’re not sure which items and services Medicare covers in your area, see the question “How can I find out which dental items and services are covered by Medicare.”

If you don’t provide Medicare covered items and services, but you order covered clinical laboratory services, imaging services, or durable medical equipment, prosthetics, orthotics, and supplies (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 (PDF).

What happens if I send a biopsy for a patient on Medicare to an oral pathology laboratory?

The pathologist will not be paid by Medicare unless you have either:

  • Enrolled in Medicare to provide covered services using CMS form CMS-855-I
  • Enrolled in Medicare to order and refer using CMS form CMS-855-O
  • Formally opted-out

The same is true of imaging services and DMEPOS. Remember, opting out is not the same as doing nothing. Also, remember that with very limited exceptions, a dentist who opts out cannot be reimbursed by a Medicare Advantage plan, and neither can the patient.

What is the purpose of the regulation requiring dentists to enroll or opt out to order imaging services, clinical laboratory services, and DMEPOS?

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.

Read the regulation.

Frequently asked Medicare enrollment questions

I provide Medicare-covered items and services. How do I enroll in Medicare?

CMS states, “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.

  • You must first obtain and use an NPI. If you don’t already have one, you may download and print an NPI enrollment form (PDF) or you may file the form online.
  • If you enroll using a hard copy form, mail the completed form to the Medicare Administrative Contractor (MAC) that services your state. CMS has made available a list of MACs by state (PDF).
    • You’ll need to send it to every Part B entity listed in the state(s) where you practice.
    • Please remember that you are looking for the Part B (physician and non-physician provider) addresses, not Part A.
    • Here are links to the enrollment forms in PDF format:
  • As an alternative, you can enroll online using the CMS PECOS website.

For more information about enrolling in Medicare, visit CMS Medicare Provider Enrollment.

Which NPI needs to be on the claim: Type I or Type II?

Type I (individual) NPIs must be on claim forms, not Type II (organizational) NPIs.

I'm not sure if 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.

For more information see page four of the CMS fact sheet Medicare Enrollment Guidelines for Ordering/Referring Providers (PDF).

What is the difference between the CMS-855-I and CMS-855-O?

CMS-855-I is used if you intend to provide Medicare-covered items or services.

CMS-855-O is significantly easier to complete, and is used so that Medicare will cover any of the following that you order for Medicare beneficiaries: clinical lab services, imaging services, and Durable Medical Equipment, such as oral sleep apnea devices. Such dentists are sometimes referred to as “ordering/referring” providers.

How long does it take for my CMS-855-O to be processed?

CMS states that it could take 45-60 days, sometimes longer, for Medical Administrative Contractors to process enrollment applications. All enrollment applications, including those submitted over the web, require verification of the information reported. MACs may sometimes request additional information in order to process the enrollment application.

I don't provide Medicare covered items or services, but I do order covered imaging, clinical laboratory, and DME. How do I enroll?

Dentists may use the simplified enrollment form CMS-855-O (PDF), which CMS developed for dentists and other healthcare professionals who wish to enroll only to order and prescribe for Medicare beneficiaries.

Additional information about enrolling only to order imaging, clinical laboratory, and DMEPOS (but 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 enroll only to order imaging, clinical laboratory, and DME 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.

Form CMS-855-O is available in hard copy format and there is an electronic version (PDF) on PECOS.

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).

My Medicare-enrolled patient has a private dental benefit plan and it is not a Medicare Advantage plan. Must I enroll in Medicare to treat this patient?

No.

What if I enroll in Medicare using CMS-855-O, but later wish to enroll to be reimbursed by Medicare?

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 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 sheets Medicare Enrollment Guidelines for Ordering/Referring Providers (PDF) and PECOS FAQs (PDF).

When I tried to enroll using either the CMS-855-I or CMS-855-O form, I did not see general dentistry (or my particular dental specialty) listed. What should I do?

Oral surgeons should use “maxillofacial surgery”

All other dentists should use “oral surgery (dentist only).” This applies to general dentists and any specialist other than oral and maxillofacial surgeons.

Other general Medicare questions

How do I opt out of Medicare?
To opt out of Medicare, a dentist must file an affidavit (PDF) with each applicable Medicare carrier and enter into written private contracts (PDF) 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 (PDF) of the CMS Medicare Benefits Policy Manual. Information is also available on the CMS website Ordering & Certifying page. The ADA resource Opting Out of the Medicare Program contains a general discussion of the opt-out procedure. The 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.

NOTE: Medicare-eligible patients must be given notice that you’ve opted out of Medicare before covered services are delivered. This is accomplished by having the patient sign the Private Contract. ADA has made available a sample private contract (PDF).

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.

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, or DMEPOS supplier.

What is the impact of opting out if I supply oral sleep apnea devices?

Oral sleep apnea devices may be covered by Medicare as DME. A dentist who wishes to receive reimbursement from Medicare for supplying oral sleep apnea devices must enroll as a DMEPOS supplier using the CMS-855-S (PDF) form.

By itself, enrolling as a DMEPOS supplier does not satisfy the requirement for Medicare reimbursement for other Medicare covered services. A dentist must also either enroll (using the 855-I or the 855-O form, as appropriate) or opt out as described in other parts of this FAQ for other Medicare issues. CMS has advised ADA: “Dentists are permitted to opt out individually even though they are associated to an enrolled DMEPOS supplier.”

If I opt-out of Medicare, how long does it last?

Opt-out affidavits signed on or after June 16, 2015, will automatically renew every two years. If a dentist who files a valid affidavit effective on or after June 16, 2015, does not want the opt-out to automatically renew at the end of a two-year opt-out period, the dentist may cancel the renewal by notifying all MACs with which the dentist filed an affidavit in writing at least 30 days prior to the start of the next opt-out period. Valid opt-out affidavits signed before June 16, 2015 will expire two years after the effective date of the opt-out.

If I opt out of Medicare, can I opt back in before the end of the two-year period?

A dentist who opts out of Medicare for the first time may terminate the opt out by notifying all MACs with which the dentist filed an opt out affidavit within 90 days of filing the opt out affidavit. The dentist must also refund any beneficiary with whom the dentist had a private contract all payment collected in excess of the Medicare limiting charge. The dentist must also notify all beneficiaries with whom he or she entered into private contracts of the dentist’s decision to terminate the opt out and of the beneficiaries’ right to have claims filed on their behalf with Medicare for the services furnished during the period between the effective date of the opt-out and the effective date of the termination of the opt out period.

Read the federal regulations on opting out.