Medicare processing system to be overhauled for dental claims

The U.S. Centers for Medicare and Medicaid Services (CMS) is updating its claims processing system to align with dental standards following its 2022 rule that expanded access to dental care by finalizing payment for services deemed “integral to covered medical services.”

Wisconsin-based technology provider Flexion announced on July 10 that it won the modern claim adjudication development services contract with CMS to modernize the agency’s system to accommodate the acceptance, adjudication, and payment of dental claims under qualifying covered medical services. In November 2022, the CMS Calendar Year 2023 Physician Fee Schedule final rule was released, clarifying and finalizing policies in which Medicare Parts A and B will pay for dental services when they are essential to the specific treatment of a beneficiary’s primary medical condition.

Additionally, Medicare will pay for services, including dental exams and treatment to or simultaneously with organ transplants and cardiac valve replacements. Coverage began in 2023.

Prior to the establishment of the final rule, the ADA fought against measures to expand care through Medicare Part B. However, the tide changed in September 2022 when the ADA announced that it supported the new CMS physician fee rule but wanted the agency to address issues related to the administration and reimbursement of benefits. At the time, the ADA noted that it was concerned about costs and their management if dental services were made available to vulnerable Medicare recipients.