The Centers for Medicare and Medicaid Services (CMS) finalized CMS-4159-F Medicare Program; Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs rule in May of 2016 that requires all physicians and eligible professionals-including dentists-who prescribe Part D covered drugs to be enrolled in Medicare in an approved status or opt out for those prescriptions to be covered under Part D.

This policy requires all prescribers of Part D drugs to take action to either submit their Medicare enrollment applications or opt-out affidavits to Palmetto GBA, which is the Medicare Administrative Contractor (MAC). Sending these in a timely manner ensures that Palmetto GBA has sufficient time to process your application or opt-out affidavits which will avoid your patient’s prescription drug claims from being denied by their Part D plans beginning December 1, 2015. (The new effective date for this requirement is January 1, 2019.)

While the full enforcement date is January 2019, CMS encourages all providers who prescribe Part D drugs, but are not yet enrolled or validly opted out of Medicare, to enroll in the Medicare Program now.

In the lead-up to the January 1, 2019 full enforcement date, CMS will begin phasing in targeted enforcement of the regulation and undertake the incremental strategic actions designed to increase on-going prescriber enrollment, while protecting beneficiaries and the Medicare program.

Information regarding incremental strategic actions can be found in CMS MLN SE1434 (PDF, 86 KB).

More details regarding the phase in period are available in the CMS Prescriber Enrollment Fact Sheet (PDF, 103 KB).

Getting Started:  Submitting an application to Palmetto GBA
Medicare enrollment application forms are fillable on your computer. This means that you can fill out the information required by typing into the open fields while the form is displayed on your computer monitor. Filling out the forms this way before printing, signing and mailing means more easily-readable information – which means fewer mistakes, questions and delays when your application is processed. Be sure to make a copy of the signed form for your records before mailing. Signatures are still required to be handwritten on this document so don't forget to complete this important step prior to mailing your application(s). Mail your completed application to:  

Standard Mail:

Palmetto GBA
Part B Provider Enrollment (AG-310)
PO Box 100306
Columbia, SC 29202-3306 


Palmetto GBA
Attn: Provider Enrollment
2300 Springdale Drive
Building One
Camden, SC 29020-1728

Keep in mind that typed forms are easier for Medicare to process, but the most efficient method for submitting your enrollment application is to use the Internet Based Provider Enrollment, Chain and Ownership System (PECOS). PECOS guides you through the enrollment application so you only supply information relevant to your application. PECOS also reduces the need for follow-up because of incomplete applications. Using Internet-based PECOS results in a more accurate application and saves you time and administrative costs.

In order for Medicare to pay for prescriptions under Medicare Part D, providers must complete one of the following applications/forms:

 Form When to Use Tips
(PDF, 234 KB)

This option is for providers seeking to enroll solely to prescribe Part D drugs.

Section 4: Medical Specialty - Select 'Dentist'

(PDF, 522 KB)

This option is for providers wishing to enroll in the Medicare program. 

Providers should select  Undefined Physician Type and specify General Dentistry.

Medicare Opt Out Affidavit
(PDF, 97 KB)

MLN about Opt Out 
(PDF, 110 KB)

This option is for providers choosing to opt out of Medicare. Paper submission only 

Selecting this option means that neither the physician, nor the beneficiary submits the bill to Medicare for services rendered. Instead, the beneficiary pays the physician out-of-pocket and neither party is reimbursed by Medicare. A private contract is signed between the physician and the beneficiary that states that neither one can receive payment from Medicare for the services that were performed.

Opt out affidavits are only valid for two years, after which the option automatically renews unless notified by the provider to end the opt-out agreement.

PECOS  Electronic Submission of CMS 855-O and CMS 855-I
To access PECOS, click on the ‘Access to Internet-Based PECOS’ Link under ‘Related Links’ located at the bottom of the page.  Please review the PECOS section prior to clicking this link.

Resources:  Palmetto GBA and CMS Website & Frequently Asked Questions (FAQs)
Palmetto GBA and CMS have a number of resources on their websites designed to assist you with this CMS initiative. We encourage you to visit the sites listed below for educational resources about this process. We have also included a link to the CMS FAQs that have been posted to their website.

Contact Palmetto GBA JJ Part B Medicare

Provider Contact Center: 877-567-7271

Email JJ Part B

Contact a specific JJ Part B department

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