Dentists Submitting Claims to Medicare

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Apr 12th, 2018

When a Dental provider is treating a Medicare Beneficiary, it is important to get a copy of the Medicare card to verify the patient's medical benefits, provider eligibility, and claims address/submission prior to submitting a claim. CMS is in the process of changing Medicare Policy Numbers, so you may see a few different cards as they are no longer issuing cards with the Beneficiary's SSN #.

Understanding Medicare

There are four parts to Medicare; the verification of benefits will let you know if the beneficiary has coverage for Part B or Part C. 

• Medicare "Part A" Inpatient/Hospital

• Medicare "Part B" Outpatient often called "Original Medicare"

• Medicare "Part C" plans are often called "Medicare Advantage" plans or "MA Plans"

• Medicare "Part D" is often called "Prescription Drug Coverage"

Billing

The billing provider must have an NPI (National Provider Identifier) and be participating with Medicare prior to billing any claims. Once this is confirmed, claims are billed on a CMS-1500 medical claim form. Be sure you are billing on the (02-12) version.

Note: CMS requires all initial claims for reimbursement (except small providers) be submitted electronically (electronic versions of the CMS-1500) with limited exceptions. Do not bill medical claims on the Dental claim form. 

When billing for something such as sleep apnea devices, the provider must be enrolled as a DME supplier. When you agree to accept assignment as a participating provider, you are contracted to accept the payment amount determined by your jurisdiction.

Payment

The contracted provider will be paid at 80% of the agreed rate, the patient will be responsible for 20% co-insurance assuming the deductible has been met.

Enrollment

Providers can enroll in Medicare by using either PECOS: go.cms.gov/pecos or by completing the paper 855I or 855O paper application.

NOTE: CMS is updating the CMS-855O to include the General Dentist option. Until that form is updated, dentists should select from either the Maxillofacial Surgery, Oral Surgery (dentist only), if applicable, or select Undefined Physician type and write in ‘General Dentist’ on the CMS-855O.

• Group Enrollment: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/CMS855B.pdf
• Individual Enrollment: https://www.cms.gov/Medicare/CMS-Forms/CMS-forms/Downloads/cms855i.pdf
• DME Enrollment: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms855s.pdf

Prescriptions

If a Dental provider writes a prescription for a Medicare beneficiary, it will only be covered if the Dental provider is enrolled in "Part D." 

If a Dental provider chooses not to enroll or opts out of Medicare, please be aware:

• Unenrolled dentists’ Medicare patients will receive written notifications in the mail that their dentist is not qualified to write Part D prescriptions when the patients fill a prescription (which will only be covered on a provisional basis).
• After a provisional supply of a drug has been covered, a Part D drug benefit plan will no longer cover a prescription written by an unenrolled dentist.   
• Unenrolled dentists who contract with managed care plans to provide dental services to Medicare beneficiaries cannot opt-out.