Have You Opted Out of Medicare?

  • March 3, 2022

    If you or a dentist in your practice has opted out of Medicare with the Centers for Medicare & Medicaid Services (CMS), you need to be aware that you can’t receive payment from CMS for any medical services provided to Medicare Advantage patients. This also means Premera can’t reimburse you for claims considered medical and covered under original Medicare (Part A or Part B). Premera can only reimburse claims for supplemental services, or for medical services provided in urgent or emergent situations.

    Supplemental services

    These are dental services and items provided in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth. Structures directly supporting the teeth mean the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. These services are covered by the plan and provided by dentists regardless of opt out status. These claims will process normally.

    If a dentist who has opted out of Medicare intends to provide non-urgent or non-emergent medical services to a Premera Medicare Advantage member, it’s critical to know:

    • Your office will need to enter into a written agreement directly with the member.
    • Members will need to pay for these services entirely out of their own pocket and they cannot receive reimbursement from CMS or Premera. Therefore, it is imperative to have a clear discussion with your patient and our member to discuss their care options and these costs.
    • Claims for these services cannot be submitted to Premera for reimbursement.

    If you haven’t opted out of Medicare, claims you submit for Part A and Part B services will process normally.

    Additional information about opting out of Medicare can be found at Noridian Healthcare Solutions.

    Learn more about CMS enrollment and restrictions.

  •    Email this article