Medicare claim denial process 

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By Craig Palmer, ADA News staff writer

Washington—Medicare will "turn on" a claim denial process May 1 affecting dentists and other health care providers ordering particular Medicare-covered items or services for Medicare beneficiaries. As of that date, a provider of a covered clinical laboratory, imaging, durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) or home health service will not be paid if the ordering or certifying practitioner has not enrolled in Medicare or properly opted out.

Medicare officials modified the proposed regulations in several respects in response to Association advocacy before issuing a final rule June 26, 2012 The Association urged that the rule should not apply to referrals to specialists, and the final rule removed this proposed requirement. Medicare officials also delayed full implementation of the Affordable Care Act requirement. 

The announcement of Phase 2 implementation in a special edition of MLN Matters includes guidance on orders or referrals by dentists.

•    "Effective May 1, 2013 the Centers for Medicare & Medicaid Services (CMS) will turn on the Phase 2 denial edits. This means that Medicare will deny claims for services or supplies that require an ordering/referring provider to be identified and that provider is not identified, is not in Medicare's enrollment records, or is not of a specialty type that may order/refer the service/item being billed."

•    "Orders or referrals by dentists: Most dental services are not covered by Medicare; therefore, most dentists do not enroll in Medicare. Dentists are a specialty that is eligible to order and refer items or services for Medicare beneficiaries (e.g. to send specimens to a laboratory for testing). To do so, they must be enrolled in Medicare. They [dentists who enroll using CMS-855O] may enroll by filling out the paper CMS-855O or they may use Internet-based PECOS. They will not be submitting claims to Medicare for services they furnish to Medicare beneficiaries." 

Phase 1 edits notified providers if the ordering or certifying practitioner was not enrolled or properly opted out but did not deny payment. The CMS uses the term "ordering/referring" to refer to practitioners who order or certify covered items and services. PECOS is the Internet-based Provider Enrollment, Chain and Ownership System.

The Association recommended  a simplified enrollment process for dentists who want to enroll in Medicare solely for ordering and certifying covered items and services, and CMS announced approval of a simplified process Aug. 16, 2010 in an online notice. This simplified enrollment process does not require the dentist's financial information because doctors who enroll only to order/certify will not be directly billing Medicare. Doctors who directly provide Medicare eligible services are not eligible for the simplified process and need to either fully enroll in Medicare or opt out.

The Association also offers resources on Medicare enrollment and Medicare opt-out procedures for members at, including a Sample Medicare Opt Out Private Contract. Non-members may obtain information by consulting the CMS agency or local Medicare contractor. Information on Medicare contractors is available through the CMS "Provider Compliance Group Interactive Map" at

Dentists ordering particular Medicare-covered items or services will be required toenroll in the government insurance program or opt out. Dentists may elect to opt out of Medicare and provide Medicare-covered services by entering written "Private Contracts" with their Medicare-eligible patients and by filing an Affidavit with each applicable Medicare carrier.

Dentist referrals to specialists are not covered by the final rule, and referral to a specialist would not require the referring dentist to enroll in Medicare. The specialist could submit a Medicare claim without having to list the referring dentist. However, dentists ordering clinical laboratory or imaging services or durable medical equipment (DME) must enroll in Medicare or opt out for providers of those services to be reimbursed by Medicare.

Dentists referring Medicare patients to other health care professionals, oral surgeons for example, would not have to enroll or formally opt out of Medicare. But dentists who perform Medicare eligible procedures such as biopsies should fully enroll or opt out.

Oral pathologists have reported to the ADA that they bill their services to Medicare as clinical laboratory services. Therefore, ordering the pathology review of specimens will require the ordering dentist to enroll or opt out.

The MLN Matters notice advises, "If you order or refer items or services for Medicare beneficiaries and you do not have a Medicare enrollment record, you need to submit an enrollment application to Medicare…Waiting too long to begin this process could mean that your enrollment application may not be processed prior to the May 1, 2013 implementation date of the ordering/referring Phase 2 provider edits."

In Phase 2 implementation, if the ordering/referring provider does not pass the edits, the claim will be denied. This means that the Medicare billing provider will not be paid for the items or services that were furnished based on the order or referral, CMS said. If oral pathologists cannot receive payment for their services due to lack of enrollment, they may decline to accept specimens from doctors who are not enrolled.

The Medicare Learning Network notice is intended for physicians, including dentists, and non-physician practitioners including interns, residents, fellows and providers employed the Department of Veterans Affairs, Department of Defense or Public Health Service who order or refer items or services for Medicare beneficiaries and other Part A and Part B providers and suppliers.


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