130 C.M.R. 420.401 – Introduction

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth

Table of Contents iv

Provider Manual Series

Transmittal Letter Date

Dental Manual

DEN-111 10/15/21

4. Program Regulations: Dental Services

420.401: Introduction .......................................................................................................... 4-1 420.402: Definitions ............................................................................................................ 4-1 420.403: Eligible Members ................................................................................................. 4-2 420.404: Provider Eligibility: Participating Providers ....................................................... 4-2 420.405: Provider Eligibility: In-state and Out-of-state ...................................................... 4-3 420.406: Caseload Capacity ................................................................................................. 4-4 420.407: Maximum Allowable Fees ................................................................................... 4-4 420.408: Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services….. . 4-4 420.409: Noncovered Circumstances .................................................................................. 4-4 420.410: Prior Authorization ................................................................................................ 4-5 420.411: Pretreatment Review ............................................................................................ 4-6 420.412: Individual Consideration ...................................................................................... 4-6 420.413: Separate Procedures .............................................................................................. 4-7 420.414: Recordkeeping Requirements ............................................................................... 4-7 420.415: Report Required with Certain Claims .................................................................. 4-8 420.416: Pharmacy Services: Prescription Requirements ................................................... 4-8 (130 CMR 420.417 through 420.420 Reserved) 420.421: Covered and Noncovered Services: Introduction ................................................. 4-9 420.422: Service Descriptions and Limitations: Diagnostic Services ................................. 4-10 420.423: Service Descriptions and Limitations: Radiographs ............................................ 4-11 420.424: Service Descriptions and Limitations: Preventive Services ................................. 4-14 420.425: Service Descriptions and Limitations: Restorative Services ................................ 4-15 420.426: Service Descriptions and Limitations: Endodontic Services ................................ 4-16 420.427: Service Descriptions and Limitations: Periodontal Services ................................ 4-18 420.428: Service Descriptions and Limitations: Prosthodontic Services (Removable) ...... 4-18 420.429: Service Descriptions and Limitations: Prosthodontic Services (Fixed) ............... 4-20 420.430: Covered Service Descriptions and Limitations: Oral and Maxillofacial

Surgery Services ................................................................................................... 4-20

420.431: Service Descriptions and Limitations: Orthodontic Services .............................. 4-23 (130 CMR 420.432 through 420.451 Reserved) 420.452: Service Descriptions and Limitations: Anesthesia .............................................. 4-26 420.453: Service Descriptions and Limitations: Oral and Maxillofacial Surgery

Services Performed by Specialists in Oral Surgery ............................................... 4-27

(130 CMR 420.454 Reserved) 420.455: Service Descriptions and Limitations: Maxillofacial Prosthetics ......................... 4-29 420.456: Service Descriptions and Limitations: Other Services ......................................... 4-29

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-1

Provider Manual Series (130 CMR 420.000)

Transmittal Letter Date

Dental Manual

DEN-111 10/15/21

(A) 130 CMR 420.000 contains the regulations governing dental services under MassHealth. All dental providers participating in MassHealth must comply with MassHealth regulations, including but not limited to 130 CMR 420.000 and 450.000: Administrative and Billing Regulations.
(B) As described in 130 CMR 420.000 and in 450.000, covered dental services are more extensive for members younger than 21 years old than for members 21 years of age and older.
(C) Subchapter 6 of the Dental Manual lists the Current Dental Terminology (CDT) codes for dentists and public health dental hygienists and Current Procedural Terminology (CPT) codes for specialists in oral surgery that the MassHealth agency pays for, a description of those codes, and where indicated, prior-authorization requirements. Oral and maxillofacial surgeons must submit all claims containing CPT codes directly to MassHealth.