Disclaimer: Insurance administration and dental billing recommendations, as well as interpretations of the CDT codes, represent the opinions of our experts. For the latest CDT codes and official interpretations, contact the American Dental Association or visit ADA.org. You are responsible for your own use of the CDT Codes, insurance administration, and dental billing.

The Business of Medicare: Enrollment and Non-covered Services

In the dental world, the word “Medicare” has typically made us want to run screaming for the hills. For a long time, the general consensus was, “We don’t take Medicare, so we don’t have to worry about it.” Unfortunately, that is no longer the reality. Between shifting regulations and the rise of Medicare Advantage, ignoring Medicare is not an option or a viable strategy for most dental practices.

Medicare rules apply to your office.

Enrolling as a Medicare part B provider is a good choice for providers who perform covered Medicare procedures. Under Medicare, dentists are classified as physicians, which means that if a dentist treats a Medicare beneficiary, the dentist must choose one of these three main pathways:

1. Becoming a Participating Provider: The dentist accepts Medicare’s fee schedule and gets paid directly by Medicare. You submit a Participating Provider Agreement, agree to Electronic Funds Transfer, and receive a 5% higher reimbursement than non-participating providers.
2. Being a Non-participating Provider: The dentist can decide to accept assignment on a case-by-case basis. If you do not accept assignment, payment would go directly to the patient instead, and the office is restricted to a “limiting charge” of 115% of the Medicare Physician Fee Schedule amount. That means the office can charge up to a maximum of 15% above the approved amount for the service.
3. Formally Opting Out: The dentist signs a private contract with the patient, under which the patient pays the office directly. No claims go to Medicare with this option. This status requires an affidavit be sent to your Medicare Administrative Contractor – or MAC – and must be renewed every two years.

What is an Ordering and Referring provider and a DME supplier?

Dentists who don’t offer Medicare-covered services can still enroll solely as Ordering and Referring providers. This status does not exempt you from mandatory filing laws, but it does ensure Medicare recognizes your NPI. To qualify, you must either formally enroll or file an opt-out affidavit. While you won’t be submitting claims, this status is essential for allowing other physicians and suppliers to receive payment for the tests or equipment you authorize for your patients.

If you’re looking to dive into the world of sleep medicine, keep in mind that oral appliances for obstructive sleep apnea (OSA) are covered under Medicare’s Durable Medical Equipment (DME) benefit. To successfully file these claims, and get paid, your practice’s billing entity must be specifically enrolled as a DME supplier. Any dentist who enrolls as a DME supplier could, but is not required to, also maintain a concurrent enrollment as either a Part B provider or an ordering/referring physician to provide other potentially covered services that Medicare allows. When it comes to treating OSA, a DME supplier cannot also prescribe or administer the sleep study. They would verbally refer the patient back to their primary care physician (PCP) and follow up to receive a copy of the test. Documentation of the face-to-face visit with their PCP discussing the sleep test and options to treat the sleep disorder is required.

Enrolled providers are required to notify patients if Medicare may not cover services they are about to receive.

Most routine dental work is still excluded by Medicare. If you do perform a service that is covered, you must submit the claim and follow Medicare guidance. If you are enrolled and are about to perform a service that Medicare might not cover, you need to use the Advance Beneficiary Notice (ABN). This document informs the patient that Medicare might not pay for the service, and if it does not, the patient is responsible for the cost.

An ABN should not be used to avoid filing a claim to Medicare, as all providers must file claims for potentially covered services, unless they have officially opted out. Additionally, ABNs are only used by physicians and suppliers who are enrolled with Medicare. Dentists who have opted out or are only enrolled as Ordering and Referring providers are not to utilize the ABN.

Whether you choose to dive into the Medicare pool or just dip a toe in as a referring provider, making a conscious decision is the only way to stay compliant. Most routine dental work is still excluded, but once you step into the realm of covered services, you need to have your paperwork in order — including using an Advance Beneficiary Notice (ABN) to notify patients when Medicare might not foot the bill.

For more on Medicare, including additional details on the information in this post, see the 30-page section on Medicare in our 2026 publication of Dental Administration with Confidence.

Source:

Practice Booster (2026). Dental Administration with Confidence (pp. 141-144). 2025 eAssist Publishing, LLC.