Medicare Advantage Plan Reimbursement


January 25, 2017


Do you have patients over the age of 65 with dental insurance? Then you MAY have patients in Medicare Advantage Plans. To receive reimbursement from a Medicare Advantage Plan the Centers for Medicare & Medicaid Services (CMS) requires you to enroll with Medicare as either:

  1. A Medicare provider (use form 855I or internet-based PECOS): Use this if you do biopsies, extractions prior to radiation therapy or any other procedure covered by Medicare Part B.
  2. An ordering/referring provider (use form 855O or internet-based PECOS : Use this if you do NOT perform any service covered by Medicare Part B.

If you do nothing or opt-out you will not be reimbursed by Medicare Advantage Plans. The insurance these patients present with will look the same and claims you send will be the same as plans your younger patients have. Companies like Aetna, Delta, etc. provide Medicare Advantage Plans. This has nothing to do with the delayed enforcement of the Medicare Part D (prescription coverage) prescriber enrollment requirement.


Also note: If you fabricate devices covered by Medicare like approved sleep apnea devices you must enroll with CMS as a provider of durable medical equipment (DME) (use form 855S or internet-based PECOS). Enrollment as a DME provider is unrelated to the new requirements for Medicare Advantage Plans or Part D coverage.


The application process is not difficult - you do not need to pay anyone to fill the forms out for you. Do not delay! This is effective now.