ACM Part B Questions and Answers - July 20, 2023

The following questions and answers (Q&As) are cumulative from the Dental Services Part B Ask the Contractor Meeting (ACM). Some questions have been edited for clarity and answers may have been expanded to provide further details. Related questions were combined to eliminate redundancies. If a question was specific just for that office, Noridian addressed this directly with the provider. This session included pre-submitted questions and verbal questions posed during the event.

Updates and Reminders:

  • If patient has managed care or Railroad Medicare, instead of traditional fee-for-service Medicare, do not bill Noridian
  • Seek external sources for coding advice

Pre-Submitted Questions:

Q1. Why are emergency services for abscesses not covered?
A1. Every clinical situation differs. E/M services may be covered for an initial evaluation in the emergency department depending on the situation. However, if the provider is there to evaluate and treat what is considered to be a "dental service", it is important to remember that the statutory exclusion for dental services still applies and therefore the service would most likely be denied.

Q2. Would like to better understand how Noridian is determining "inextricably linked"?
A2. CMS defines "inextricably linked" as dental services that are substantially related and integral to the clinical success of a medically necessary service, such that if those dental services were not performed prior, it would result in a material difference in terms of clinical outcomes and success of that medical procedure or service.

The primary medical service must be covered by Medicare. There must be demonstration of care coordination between the dental provider and the health care professional involved with the primary medical service. The link to dental services as it relates to the clinical success of a procedure/service must be supported by clinical evidence- such as peer-reviewed evidence-based literature and/or specialty society endorsed clinical guidelines.

Some examples of situations of an inextricable link between dental services and other Medicare-covered services could include:

Dental or oral exams as part of a comprehensive workup prior to, and medically necessary diagnostic and treatment services to eliminate an oral or dental infection prior to or contemporaneously with, a Medicare-covered:

  • Organ transplant, including hematopoietic stem cell and bone marrow transplant
  • Cardiac valve replacement
  • Valvuloplasty

Without care coordination, health care providers won’t have the information they need to decide whether a dental service is inextricably linked to a Medicare-covered service. If the health care providers don’t coordinate care, Medicare won’t cover and pay for dental services. Examples of care coordination may include a referral or exchange of information between a medical doctor and a dentist. This must be documented.

See: CMS Medicare Dental Coverage

Q3. Are all dental services going to be covered (preventive, routine, etc.) or only dental services deemed medically necessary?
A3. As the statutory exclusion for dental services still applies, cleanings, fillings, removals, replacement of teeth and other dental services (for the sole purpose of care to the teeth and/or supporting structures) are not covered. Preventive screening services are not covered unless specifically noted by CMS.

Q4. Interested in options for submitting claims when the dentist does not have access to electronic claims software. (Endodontist in private practice?)
A4. Mandatory electronic claims filing requires that all initial claims be submitted electronically with limited exceptions. The exception can apply to small providers defined as those with fewer that 10-full time employees. Providers will need to work with the Electronic Data Interchange (EDI) department to have a waiver added to their enrollment application.

Q5. How will a patient who sees a non-participating provider be able to submit an electronic claim?
A5. Medicare enrolled providers are required to submit claims to Medicare on behalf of the beneficiaries. It does not matter if they are enrolled as and accept assignment as a "Participating" or "Non-Participating" providers. There are a few exceptions for a complete list of the exceptions and instructions

Q6. When and how to use the advanced beneficiary notice of non-coverage (ABN)?
A6. If the dental services performed are found NOT to be inextricably linked, then they are considered a non-covered benefit under the statutory exclusion for dental services. Technically an ABN is not required, however, Noridian and CMS strongly encourages use of an ABN to ensure that beneficiaries are aware of the possible financial implications as it relates to non-covered beneficiary payment responsibilities.

No further questions were asked during the ACM.


Last Updated Aug 22 , 2023