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Medicare Decision Tree

If you are unsure about enrolling or opting out of Medicare, use this easy flowchart to figure it out. Click to enlarge.

UPDATE: CMS has announced that full enforcement of the Part D prescriber enrollment requirement will begin on January 1, 2019.

If you have more questions, you can contact the ADA to discuss your options at 312.440.2500

[Click to Enlarge Decision Tree]

1Dental services covered by Medicare. Medicare covers a very limited number of dental services, such as the extraction of teeth to prepare the jaw for radiation treatment, or an oral exam performed on an inpatient basis prior to renal transplant surgery (see CMS, Medicare Dental Coverage). However, certain biopsies performed in a dental office may be covered by Medicare.

How do I know whether a patient is on Medicare? Medicare is a health insurance program for people age 65 or older, people under age 65 with certain disabilities, and people of all ages with End-Stage Renal disease. You can only find out whether a patient is on Medicare by asking the patient or the patient’s legal representative.

2Form CMS-855I. You can use the paper or electronic form (see CMS, Enrollment Applications).

What if I’m already enrolled, but as a DME supplier? If you also provide covered services, you must also enroll using CMS-855I. If you order/refer but you do not provide covered services, you must enroll using form CMS-855O (you may also use CMS-855I).  

3Opting Out. Opting out requires you to file an affidavit with all applicable Medicare contractors and enter into private contracts with patients who are Medicare beneficiaries. Opting out lasts for two years. (see ADA, Opting Out of the Medicare Programand Medicare Opt-Out FAQ, CMS, Opting Out of Medicare and/or Electing to Order and Refer Services(PDF). Note that dentists who opt out of Medicare cannot submit claims to a Medicare Advantage plan or receive reimburse¬≠ment from Medicare for covered items such as sleep apnea devices.  

4Ordering and referring. For example, some oral pathology services are covered clinical laboratory services, and in some cases oral sleep apnea devices may be covered DMEPOS. Medicare will not pay for the clinical laboratory or imaging service or the DMEPOS if the ordering or referring dentist is not enrolled or formally opted out. For more information, see CMS, Medicare Enrollment Guidelines for Ordering/Referring Providers (PDF).

5Form CMS-855O. You can use the paper or electronic form (see CMS, Enrollment Applications). Note: If you only order/refer, you may choose to enroll as a Medicare provider using the longer form CMS-855I, but that offers no advantage if you are not seeking to provide Medicare covered services.

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