A Guide to Medicare Dental Provider Enrollment
Dentists’ Medicare enrollment
If you want to enroll in Medicare, you must have a National Provider Identifier (NPI). The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).
Once you have been issued with NPI, you may apply for enrollment in the Medicare program or make a change in enrollment information using the paper application process (Form CMS-855) or the Internet-based Provider Enrollment, Chain, and Ownership System (PECOS).
PECOS online applications are handled more quickly than paper applications. PECOS is paperless; you do not have to submit anything by mail that can take days or sometimes even weeks. Additionally, PECOS is accurately prepared to ensure that you only give information that applies to your application. To help and guide you, the PECOS system has video and print tutorials to get you started.
Advantages of opting in:
- You’ll be listed in Delta Dental’s Medicare Advantage network directory.
- You’ll ensure payment as an in-network dentist for treatment you provide Medicare Advantage patients with plans offered through the Delta Dental network.
- The Medicare Advantage plan will cover your prescriptions for Medicare patients.
- You’ll remain in Delta Dental’s network (since several of our Medicare Advantage partners require us to terminate dentists’ participation contracts who opt-out or do nothing).
This is an essential part of Dentists’ Medicare Enrollment that you need to understand. Healthcare providers must be enrolled in the Medicare program if they want to receive payment for covered services provided to their Medicare beneficiaries.
Enrolling in Medicare ensures payments, and it is a way to continue excellent and lasting patient relationships. The majority of dentists choose to participate in Medicare, but some do opt-out.
What does it mean to “opt-out” of Medicare?
Opting out of Medicare means that you have decided not to participate in the Medicare program. Dental practitioners who choose to opt-out may enter private contracting agreements with Medicare beneficiaries and charge patients without being subject to the Medicare physician fee schedule.
Once you have opted out of Medicare, know that you cannot submit claims to Medicare for any of their patients for two years.
A provider who opts out may order, certify, or refer a beneficiary for Medicare-covered items and services as long as you are not reimbursed for the services, except for emergency and urgent care services.
Dangers of opting out or doing nothing:
- By opting out, you’ll be excluded from participation in Delta Dental’s Medicare Advantage network for two years under present Medicare regulations.
- If you do nothing (neither opt-in nor opt-out), your Part D prescriptions will not be covered.
If you wish to opt-out, you must:
- Submit an Opt-Out Affidavit expressing your decision to opt-out
- Sign private Medicare Opt-Out Private Contracts
- Be legally authorized to practice dentistry, podiatry, optometry, medicine, or surgery by the state in which such function or action is performed
- Be legally authorized to practice by the state and otherwise meet Medicare requirements
See the table below for provider types who may or may not opt-out.
|Providers Eligible to Opt-Out||Providers NOT Eligible to Opt-Out|
|Doctors of medicine||Groups/Organizations|
|Doctors of osteopathy||Part A enrollments|
|Doctors of dental surgery or dental medicine||Chiropractor|
|Doctors of podiatric medicine||Anesthesiologist assistant|
|Doctors of optometry||Speech-Language Pathologist|
|Physician assistants||Physical Therapists|
|Nurse practitioners||Occupational Therapists|
|Clinical nurse specialists||Any specialty not eligible to enroll in Medicare|
|Certified registered nurse anesthetists|
|Clinical social workers|
|Registered dieticians and nutrition professionals|
Here the three common concerns of healthcare providers about Dentists’ Medicare Enrollment and opting out.
Renewal of Opt-Out Status
- Current opt-out providers are automatically renewed every two (2) years.
- Notification letters will be sent 90 days before the opt-out is due to renew. The letter warns that the opt-out will be renewed soon.
- If you wish to terminate your auto-renewal, you must submit the cancellation request through a letter 30 days before the opt-out is in line for expiration.
Cancellation of Opt-Out Status
If you now wish to end your opt-out status and re-enroll in Medicare, then you must submit the cancellation request via a letter 30 days before the opt-out is due to expire. You need to remember that if your cancellation letter is offered after 30 days, you will remain opted out for another 2-year cycle.
A provider opt-out status may be voluntarily terminated within 90 days of the affidavit if a provider has not previously been in an opt-out status. This only applies to initial opt-out providers. This does not apply to providers who renew their opt-out status.
If you found this guide helpful, feel free to schedule a call with us to know more about medical billing or follow OneMedAll to be updated all about dental health.
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