Medicare Resources

MEDICARE DECISION TREE

Medicare Guide for Dental Professionals:

Understanding the Changes

General Information
Do you treat
any patients age
65 or older or in
end stage renal
disease?

Are you a
Medicare DME
provider for
sleep apnea
appliances?

YES

Do you want
to collect
Medicare for
other covered
services?

YES

Center for Medicare and Medicaid

YES

Go to
Option 2

www.cms.gov
Medicare Administrative Contractor State Directory

www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/
Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map

NO
NO

Enrollment Information

NO

Do you
ever write
prescriptions for
friends, family,
or emergency
patients?

PECOS Online Enrollment Site

Go to
Option 1

YES

https://pecos.cms.hhs.gov/pecos/login.do

Go to
Option 1

SEPTEMBER 1, 1990
The Social Security Act (Section 1848(g)
(4)), became effective, requiring all
potentially covered services be filed
with Medicare.

OCTOBER 9, 2009

Medicare Guide for Enrollment as an Ordering/Referring Provider (Option 1)

Do you
want to collect
from Medicare
for covered
services?

NO

Go to
Option 4

Go to
Option 1

NO

Will you enter

into private
contracts with
all Medicare
patients?

YES

YES

Go to
Option 2

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/

Medicare began alerting physicians

downloads/MedEnroll_OrderReferProv_FactSheet_ICN906223.pdf

that enrollment would be required

Medicare Guide for Enrollment as a Part B Provider (Option 2)

Go to
Option 3

MAY 23, 2014

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/
downloads/MedEnroll_PhysOther_FactSheet_ICN903768.pdf

The Centers for Medicare and Medicaid

Medicare Guide for Opting Out (Option 3)

Medicare Program; Contract Year 2015

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNMattersArticles/downloads/SE1311.pdf

Policy and Technical Changes to the

for any providers who order tests

(including lab and radiology tests).

Services (CMS) finalized CMS-4159-F,

Medicare Advantage and the Medicare

Prescription Drug Benefit Programs.

Medicare Guide for Enrollment as a DME Provider

JUNE 1, 2015

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/
downloads/MedEnroll_PECOS_DMEPOS_FactSheet_ICN904283.pdf
OPTION 1

OPTION 2

OPTION 3

OPTION 4

Enroll as Ordering/
Referral Provider

Enroll as Part B Provider

Opt Out of Medicare Program

No Action Required

Allows provider to write

prescriptions and order or
refer for tests or additional
treatment.
Does not require or allow
filing claims to Medicare.
Has no effect on services
excluded by Medicare.

Does not affect services

excluded from Medicare such
as routine dental procedures.
Services covered by Medicare,
such as biopsies, will be paid
at Medicare allowable fees.
Providers will file claims and
Medicare rules will apply to
all covered services and
claims filed.

Prescriptions written by opted out

providers will be covered by Medicare.
Any testing, such as pathology, will be
paid to the laboratory providing the test.
The opt out period is valid for two years
at which time the provider must choose
to either renew the opt out or enroll.
Providers can not choose to enroll
during the opt out period.

Providers who never

expect to treat or
write prescriptions
for Medicare covered
patients are not
required to enroll or
opt out of Medicare.

DECEMBER 1, 2015

Effective Date for New Policy; Deadline

for submission of Medicare enrollment
applications or Opt-out affidavits to
allow time for processing.

Enforcement Date for New Policy

Please be aware any references to Medicare Enrollment is for
informational purposes only. Selection of Medicare option and completion of applicable
paperwork is the sole responsibility of the billing party.
2015 Henry Schein, Inc. No copying without permission. Not responsible for typographical errors. 15DL3519

MEDICARE UPDATE

MEDICARE OPTIONS

FAQs

To date, the impact of Medicare on dental

Option 1: Enroll as Ordering/Referral Provider

Why Should You Opt Out as Opposed to Not Enrolling?

This status allows providers to write prescriptions and order or refer for tests or additional treatment. It does not

When you formally opt out you are allowed to enter into private contracts for covered services. The patient will

require or allow filing claims to Medicare. This status has no effect on services excluded by Medicare. You can enroll

pay your fee up front and no claims are filed either by your office or by the patient. You are allowed to charge your

as a Medicare Ordering/ Referring Provider either through the Internet based PECOS system or by completing the

full fee and are not subject to Medicare fee schedules. This is not permitted under any other Medicare enrollment

855O enrollment form. You can access each of these through the CMS website or by contacting your local Medicare

status. Any service ordered by a non-enrolled physician will not be covered. If you have opted out, covered

contractor for assistance.

benefits will be paid, as long as an active Medicare provider provides them. Each Medicare covered patient must

professionals has been minimal. Most dental

services are excluded under Medicare. Routine
cleanings, fillings, extractions, crowns, and
root canals are never covered. If these are the
only services you provide and/or you never
expect to see a Medicare eligible patient in your
practice, then you may feel that Medicare rules
do not apply to your practice.

have a signed private contract for each provider in the practice who may provide treatment. This contract must be

Option 2: Enroll as Part B Provider

renewed with every two year opt out period.

This enrollment does not affect services excluded from Medicare such as routine dental procedures. Services covered
If you occasionally treat patients for oral cancer or see patients with traumatic injuries, such as fractures or lacerations,

by Medicare, such as biopsies, will be paid at Medicare allowable fees. Providers will file claims and Medicare rules will

then you should examine your enrollment status with Medicare.

apply to all covered services and claims filed.

If you ever see Medicare patients for potentially covered services, you are already subject to Medicare rules, even if you are

What if my Office Provides Medicare Covered Services?

If you provide and bill for services covered by Medicare you will be required to file claims. Some of the most

Option 3: Opt-Out of Medicare Program

common covered services are biopsies, treatment of infections, treatment for trauma, and extractions prior to

either as a participating or non-participating provider. Some of the most common covered services are biopsies, treatment

Prescriptions written by opted out providers will be covered by Medicare. Any testing, such as pathology, will be paid

head or neck radiation. There are many cases where dental providers may see patients for Medicare covered

of infections, treatment for trauma, and extractions prior to head or neck radiation. Some reconstruction following cancer

to the laboratory providing the test. The opt out period is valid for two years at which time the provider must choose

treatment may be a covered service. Consultations for medical conditions, such as TMJ, are covered, as are some other

to either renew the opt out or enroll. Providers cannot choose to enroll during the opt out period. Opting out applies

medically necessary treatments. If you do not want to provide care to the Medicare population or enroll in the Medicare

only to procedures that are potentially Medicare covered services. This does not affect any procedure considered to be

program as a provider, you should opt out.

statutorily non-covered or excluded, such as routine dental work.

not formally enrolled. Any physician or dentist who provides covered services to a Medicare patient is required to enroll

There are a few exceptions to this rule, one of which concerns services provided free of charge. Many dentists have
chosen to provide free care to avoid enrollment, and, until recently, this may have been acceptable. In October 2009,
Medicare began alerting physicians that enrollment would be required for any providers who order tests (including lab
and radiology tests). Even if you do not treat (or charge) patients for Medicare covered services, you may refer a Medicare
patient for lab work or for additional studies and treatment. If you are not enrolled, these services cannot be billed by the
subsequent provider or supplier.

When you formally opt out you are allowed to enter into private contracts for covered services. The patient will pay
your fee up front and no claims are filed either by your office or by the patient. You are allowed to charge your full fee
and are not subject to Medicare fee schedules. This is not permitted under any other Medicare enrollment status. Not
being enrolled is not the same as opting out. Private contracts are not allowed or recognized as valid by Medicare
unless the doctor has opted out. Any service ordered by a non-enrolled physician will not be covered. If you have opted
out, covered benefits will be paid, as long as an active Medicare provider provides them.
If you are currently a Medicare provider, either as participating or non-participating, the choice to opt out is a business

As of January 1, 2014, any claims for services that are ordered or referred by non-enrolled practitioners are

decision based on your patient demographics and the doctors preference. If you are satisfied with your status as a

automatically rejected. This means that the lab will not be paid for submitted biopsies unless you are enrolled

Medicare provider, no action is required.

in some capacity.
To further complicate matters, in May 2014, Medicare released a final ruling stating that only drugs prescribed by a

Option 4: Do not Enroll or Opt Out/No Action

procedures. If you provide these services to Medicare patients, and wish to collect payment from either the
patient or Medicare, you must enroll as a provider or opt out.

What if my Office is Enrolled as a Medicare DME Provider?

In January 2011, Medicare approved payment for oral devices used in the treatment of obstructive sleep apnea
(OSA). This ruling stated that the devices were to be supplied and billed under the durable medical equipment
(DME) provision. Since that time, many dental offices have enrolled as DME providers and begun to accept
referrals for sleep apnea treatment. DME providers, who are enrolled as non-participating and do not accept
assignment, are not subject to Medicare fee schedules. These providers are allowed to collect fees in full upon
delivery of the appliance. Claims are submitted to Medicare as unassigned and payment goes to the patient. If
your office provides this service, it is important to know that you may NOT opt out of Medicare. This will nullify
your DME contract. Being enrolled as a DME provider does not allow you to refer patients, order tests, or write
prescriptions. If you do not expect to treat any Medicare covered services other than OSA devices, then you may
enroll as an ordering/referring provider as previously described. This will allow you to continue treating sleep
apnea patients, as well as writing prescriptions and ordering tests. Be aware that if you are treating patients for

Medicare enrolled provider will be covered. If you treat patients over 65 years of age, chances are you will need to prescribe

Providers who never expect to treat or write prescriptions for Medicare covered patients are not required to enroll

other Medicare covered services, being a DME provider does not satisfy the part B Medicare enrollment, nor does

an antibiotic, pain reliever, or other medication to a Medicare beneficiary. If you are not enrolled or have not opted out of

or opt out of Medicare. Pediatric dentists, for example, may fall into this category and may choose whether or not to

it allow you to file for those services or enter into private contracts.

Medicare, these prescriptions will not be reimbursed. Pharmacies may refuse to accept prescriptions from non-enrolled

enroll. Not being enrolled is not the same as opting out. Any service ordered by a non-enrolled physician will not be

practitioners. This requirement is expected to be enforced effective December 1, 2015.

covered. If you have opted out, covered benefits will be paid, as long as an active Medicare provider provides them.