The MassHealth agency pays for services described in 130 CMR 420.000 only to providers of dental services who are participating in MassHealth on the date of service. The participating provider is responsible for the quality of all services for which payment is claimed, the accuracy of such claims, and compliance with all regulations applicable to dental services under MassHealth. To claim payment, the participating provider must be the individual who actually performed the service, except as described in 130 CMR 420.404(A) through (D).

1. (A) A dentist or public health dental hygienist who is a member of a group practice can direct payment to the group practice under the provisions of the MassHealth regulations governing billing intermediaries in 130 CMR 450.000: Administrative and Billing Regulations. The dentist or public health dental hygienist providing the services must be enrolled as an individual provider and must be identified on claims for his or her services.
2. (B) A dental school may claim payment for services provided in its dental clinic.
3. (C) A dental clinic may claim payment for services provided in its dental clinic.
4. (D) A community health center, hospital-licensed health center, or hospital outpatient department may claim payment for services provided in its dental clinic.

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-3

Provider Manual Series (130 CMR 420.000)

Transmittal Letter Date

Dental Manual

DEN-111 10/15/21

420.405: Provider Eligibility In-state and Out-of-state

1. (A) In-state Providers. The following requirements apply when the dental provider’s practice is located in Massachusetts.

   1. (1) Dental Practitioner. A dentist engaged in private practice is eligible to participate in MassHealth as a dental provider if licensed to practice by BORID. Private practices may include, but are not limited to, solo, partnership, or group practices.
   2. (2) Community Health Center. A licensed community health center with a dental clinic is eligible to participate in MassHealth as a provider of dental services.
   3. (3) Dental School. A teaching clinic of a dental school accredited by CODA is eligible to participate in MassHealth as a provider of dental services.
   4. (4) Acute Hospital Outpatient Department, Hospital-licensed Health Center, or Other Satellite Clinic. An acute hospital’s outpatient department, hospital-licensed health center, or other satellite clinic that participates in MassHealth pursuant to the Executive Office of Health and Human Services (EOHHS) Acute Hospital Request for Applications (RFA) and contract is eligible to provide services designated as dental clinic services in Subchapter 6 of the MassHealth Dental Manual for providers under 130 CMR 420.000.
   5. (5) Dental Clinic. A dental clinic must be licensed by the Massachusetts Department of Public Health (DPH) to be eligible to participate in MassHealth as a dental provider. A DPH license is not required for a state owned and operated dental clinic. A dental clinic that limits its services to education and diagnostic screening is not eligible to participate in MassHealth as a dental provider.
   6. (6) Specialist in Orthodontics. A dentist who is a specialist in orthodontics must have completed a minimum of two years' training in a CODA advanced-education program in orthodontics that fulfills all educational requirements for eligibility for the examination by the American Board of Orthodontists.
   7. (7) Specialist in Oral Surgery. A dentist who is a specialist in oral surgery must have completed a minimum of four years' training in an oral and maxillofacial surgery advanced- education program, fulfilling the requirements for advanced training in oral and maxillofacial surgery as outlined by CODA and leading to a Certificate of Advanced Graduate Studies (CAGS).
   8. (8) Other Dental Specialists. A dentist who is a specialist in any other area of dentistry (for example, pedodontics, anesthesiology, endodontics, periodontics, or prosthodontics) must have completed the appropriate CODA-accredited certificate program that satisfies eligibility requirements for the specific specialty board.
   9. (9) Public Health Dental Hygienist. A dental hygienist engaged in private practice is eligible to participate in MassHealth as a dental provider and claim payment for certain services without the direct supervision of a dentist if he or she is licensed to practice as a registered dental hygienist by BORID and also meets the board’s requirements to practice in a public health setting pursuant to 234 CMR 2.00: General Rules and Requirements et seq. Private practices may include, but are not limited to, solo, partnership, or group practices.
   10. (10) Mobile Dental Facility (MDF) or Portable Dental Operation (PDO). A dentist or public health dental hygienist is eligible to participate in MassHealth as a dental provider and claim payment for certain services provided through a MDF or PDO only if the provider satisfies the requirements of 234 CMR 7.00: Mobile and Portable Dentistry and has obtained a valid permit as a MDF or PDO from BORID.

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-4

Provider Manual Series (130 CMR 420.000)

Transmittal Letter Date

Dental Manual

DEN-111 10/15/21

1. (B) Out-of-state Providers. A dental provider whose practice is located outside of Massachusetts is eligible to participate in MassHealth as a dental provider and to be paid for dental services provided to MassHealth members only if the provider is licensed or certified by the state in which the provider practices, meets the specific provider eligibility requirements listed in 130 CMR 420.404, and meets the conditions set forth in 130 CMR 450.109: Out of State Services.

2. (C) Enhancement Fee for Community Health Centers and Hospital-licensed Health Centers.

   1. (1) To qualify for an enhancement fee for dental services, community health centers and hospital-licensed health centers must commit to undertaking efforts that include, but are not limited to, increasing access to dental-covered services by implementing and reporting on measures to increase the capacity and volume of dental services they deliver, either directly or through subcontracts with private dental providers.
   2. (2) The dental enhancement fee is set by the Executive Office of Health and Human Services (EOHHS) (see 101 CMR 314.00: Dental Services).

420.406: Caseload Capacity

1. (A) A provider must immediately notify the MassHealth agency when its individual, group, or facility practice has reached the maximum number of MassHealth members it can accept and also when its practice is accepting new MassHealth members.
2. (B) Group practices, community health centers, hospital-licensed health centers, and acute hospital outpatient departments that choose to establish a caseload capacity must establish a single caseload capacity for the entire group or facility.

420.407: Maximum Allowable Fees

The MassHealth agency pays for dental services with rates set by the Executive Office of Health and Human Services (EOHHS) at 101 CMR 314.00: Dental Services, subject to the conditions, exclusions, and limitations set forth in 130 CMR 420.000 and 450.000: Administrative and Billing Regulations.

420.408: Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services

The MassHealth agency pays for all medically necessary dental services for EPSDT-eligible members in accordance with 130 CMR 450.140: Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services: Introduction, without regard to service limitations described in 130 CMR 420.000, and with prior authorization.

420.409: Noncovered Circumstances

1. (A) Conditions. The MassHealth agency does not pay for dental services under any of the following conditions:

   1. (1) services provided in a state institution by a state-employed dentist, dental consultant, or public health dental hygienist;
   2. (2) services provided by a provider whose salary includes compensation for professional services;
   3. (3) if, under comparable circumstances, the provider does not customarily bill individuals who do not have health insurance; and

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-5

Provider Manual Series (130 CMR 420.000)

Transmittal Letter Date

Dental Manual

DEN-111 10/15/21

1. (4) if the member is not an eligible MassHealth member on the date of service. The provider must verify the member’s eligibility for MassHealth on the date of service even if the provider has obtained prior authorization for the service.

1. (B) Substitutions.

   1. (1) If a member desires a substitute for, or a modification of, a covered service, the member must pay for the entire cost of the service. The MassHealth agency does not pay for any portion of the cost of a substitute for, or modification of, a covered service. In all such instances, before performing services not covered for the member, the provider must inform the member both of the availability of covered services and of the member’s obligation to pay for those that are not covered services.
   2. (2) It is unlawful (M.G.L. c. 6A, § 35) for a provider to accept any payment from a member for a service or item for which payment is available under MassHealth. If a member claims to have been misinformed about the availability of covered services, it will be the responsibility of the provider to prove that the member was offered a covered service, refused it, and chose instead to accept and pay for a service that MassHealth does not pay for.
   3. (3) Providers may upgrade medically necessary services at no additional cost to the MassHealth agency or the member.

420.410: Prior Authorization

1. (A) Introduction.

   1. (1) The MassHealth agency pays only for medically necessary services to eligible MassHealth members and may require that medical necessity be established through the prior authorization process. In some instances, prior authorization is required for members 21 years of age or older when it is not required for members younger than 21 years old.
   2. (2) Services requiring prior authorization are identified in Subchapter 6 of the Dental Manual, and may also be identified in billing instructions, program regulations, associated lists of service codes and service descriptions, provider bulletins, and other written issuances. The MassHealth agency only reviews requests for prior authorization where prior authorization is required or permitted (see 130 CMR 420.410(B)).

   3. (3) The provider must not start a service that requires prior authorization until the provider has requested and received written prior authorization from the MassHealth agency. The MassHealth agency may grant prior authorization after a procedure has begun if, in the judgment of the MassHealth agency

      1. (a) the treatment was medically necessary;
      2. (b) the provider discovers the need for additional services while the member is in the office and undergoing a procedure; and
      3. (c) it would not be clinically appropriate to delay the provision of the service.

2. (B) Services Requiring Prior Authorization. The MassHealth agency requires prior authorization for:

   1. (1) those services listed in Subchapter 6 of the Dental Manual with the abbreviation “PA” or otherwise identified in billing instructions, program regulations, associated lists of service codes and service descriptions, provider bulletins, and other written issuances;
   2. (2) any service not listed in Subchapter 6 for an EPSDT-eligible member; and
   3. (3) any exception to a limitation on a service otherwise covered for that member as described in 130 CMR 420.421 through 420.456. (For example, MassHealth limits prophylaxis to two per member per calendar year but pays for additional prophylaxis for a member within a calendar year if medically necessary.)

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-6

Provider Manual Series (130 CMR 420.000)

Transmittal Letter Date

Dental Manual

DEN-111 10/15/21

1. (C) Submission Requirements.

   1. (1) The provider is responsible for including with the request for prior authorization appropriate and sufficient documentation to justify the medical necessity for the service. Refer to Subchapter 6 of the Dental Manual for prior-authorization requirements.
   2. (2) Instructions for submitting a request for prior authorization for Current Dental Terminology (CDT) codes are described in the MassHealth Dental Program Office Reference Manual. Dental providers requesting prior authorization for services listed with a CDT code must use the current American Dental Association (ADA) claim form.
   3. (3) Instructions for submitting a request for prior authorization for CPT codes are described in the administrative and billing instructions (Subchapter 5) in all provider manuals. The provider must submit prior authorization requests for CPT codes to MassHealth in accordance with the instructions in Appendix A of all provider manuals.

2. (D) Other Requirements for Payment.

   1. (1) Prior authorization determines only the medical necessity of the authorized service and does not establish or waive any other prerequisites for payment such as member eligibility, the availability of other health-insurance payment, or whether the service is a covered service.
   2. (2) The MassHealth agency does not pay for a prior-authorized service when the member’s MassHealth eligibility is terminated on or before the date of service.
   3. (3) When the member’s MassHealth eligibility is terminated before delivery of a special-order good, such as denture(s) and crown(s), the provider may claim payment in accordance with the provisions of 130 CMR 450.231(B): General Conditions of Payment. Refer to 130 CMR 450.231(B) for special procedures in documenting member eligibility for special order goods.

420.411: Pretreatment Review

When the MassHealth agency identifies an unusual pattern of practice of a given provider, the MassHealth agency, at its discretion and pursuant to written notice, may require the provider to submit any proposed treatments identified by the MassHealth agency, including those not otherwise subject to prior authorization, for the MassHealth agency’s review and approval before treatment.

420.412: Individual Consideration

1. (A) Certain services, including unspecified procedures, are designated "IC" (individual consideration) in Subchapter 6 of the Dental Manual and in the EOHHS pricing regulation for dental services, 101 CMR 314.00: Dental Services. This means that a fee could not be established for these services. The MassHealth agency determines appropriate payment for individual consideration services from the provider's detailed report of services provided (see Subchapter 6 of the Dental Manual for report requirements). The MassHealth agency does not pay claims for "IC" services without a complete report (see 130 CMR 420.415). If the documentation is illegible or incomplete, the MassHealth agency denies the claim.

2. (B) The MassHealth agency determines the appropriate payment for an individual-consideration service in accordance with the following standards and criteria:

   1. (1) the amount of time required to perform the service;
   2. (2) the degree of skill required to perform the service;
   3. (3) the severity and complexity of the member's disease, disorder, or disability; and
   4. (4) any extenuating circumstances or complications.

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-7

Provider Manual Series (130 CMR 420.000)

Transmittal Letter Date

Dental Manual

DEN-111 10/15/21

420.413: Separate Procedures

Certain procedures are designated "SP" (separate procedure) in the service descriptions in Subchapter 6 of the Dental Manual. A separate procedure is one that is commonly performed as an integral part of a total service and therefore does not warrant a separate payment, but that commands a separate payment when performed as a separate procedure not immediately related to other services. For example,

1. (A) the MassHealth agency does not pay for a frenulectomy when it is performed as part of a vestibuloplasty, and full-study models are not payable separately when performed as part of orthodontic treatment or diagnosis. Nevertheless, the MassHealth agency does pay for frenulectomy as a separate procedure when medically necessary; and
2. (B) the MassHealth agency does not pay for restorations placed on two (2) or more surfaces within 12 months on the same tooth as separate restorations at the one-surface rate. Claims submitted as separate restorations will be paid at the appropriate multi-surface restoration rates set by EOHHS at 101 CMR 314.00: Dental Services, subject to the conditions, exclusions, and limitations set forth in 130 CMR 420.000 and 450.000: Administrative and Billing Regulations.

420.414: Recordkeeping Requirements

1. (A) Record Retention. Federal and state regulations require that all MassHealth providers maintain complete written records of patients who are members. All original records, including original radiographs (physical or electronic), must be kept for a minimum of four years after the date of service. Records for members who are residents of long-term-care facilities must be retained by the dentist as part of the member's dental record and by the nursing facility as part of the member’s record at the facility.

2. (B) Dental Record. Payment by the MassHealth agency for dental services listed in 130 CMR 420.000 includes payment for preparation of the member's dental record, including electronic dental records. Services for which payment is claimed must be substantiated by clear evidence of the nature, extent, and necessity of care provided to the member. For all claims under review, the member's medical and dental records determine the appropriateness of services provided to members. The written dental record corresponding to the services claimed must include, but is not limited to:

   1. (1) the member’s name, date of birth, and sex;
   2. (2) the member’s identification number;
   3. (3) the date of each service;
   4. (4) the name and title of the individual servicing provider furnishing each service, if the dental provider claiming payment is not a solo practitioner;
   5. (5) pertinent findings on examination and in medical history;
   6. (6) a description of any medications administered or prescribed and the dosage given or prescribed;
   7. (7) a description of any anesthetic agent administered, the dosage given, and the anesthesia flowsheet;
   8. (8) a complete identification of treatment, including, when applicable, the arch, quadrant, tooth number, and tooth surface;
   9. (9) dated digital or mounted radiographs, if applicable; and
   10. (10) copies of all approved prior authorization requests or the prior authorization number.

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-8

Provider Manual Series (130 CMR 420.000)

Transmittal Letter Date

Dental Manual

DEN-111 10/15/21

420.415: Report Required with Certain Claims

1. (A) The provider must submit with the claim for payment, a written description of the service provided in accordance with the requirements described in Subchapter 6 of the Dental Manual when

   1. (1) the service description in Subchapter 6 stipulates “by report;” or
   2. (2) the service is designated in Subchapter 6 as “IC”. See 130 CMR 420.412.
2. (B) The report must be sufficiently detailed to enable the MassHealth agency to assess the extent and nature of services provided.