14.01: General Provisions (1) Scope, Purpose and Effective Date. 114.3 CMR 14.00 governs the rates of payments to be used by all governmental units in making payments to eligible dental providers for dental services rendered to publicly-aided individuals on or after January 22, 2011. The rates set forth in 114.3 CMR 14.00 do not apply to individuals covered by M.G.L. c. 152 (the Workers' Compensation Act), as most recently amended by St. 1991, c. 398. Rates for service rendered to such individuals are set forth at 114.3 CMR 40.00. The codes used in 114.3 CMR 14.00 are the Health Care Financing Administration’s Common Procedure Coding System (HCPCS).
(2) Coverage. The rates of payment contained herein, or rates of payment determined in accordance with the provisions of 114.3 CMR 14.00, are full compensation for dental services rendered to publicly-aided individuals as well as for any related administrative or supervisory duties in connection with the provision of services, without regard to where these services are rendered.
(3) Authority. 114.3 CMR 14.00 is adopted pursuant to M.G.L. c. 118G.
(4) Disclaimer of Authorization of Services. 114.3 CMR 14.00 is neither authorization for nor approval of the substantive services for which rates are determined pursuant to 114.3 CMR 14.00. Governmental units that purchase services from eligible providers are responsible for the definition, authorization, and approval of services extended to publicly-aided patients.
Coding Updates and Corrections. The Division may publish procedure code updates and corrections in the form of an Informational Bulletin. Updates may reference coding systems including but not limited to the American Medical Association’s Current Procedural Terminology (CPT). The publication of such updates and corrections will list:
codes for which only the code numbers change, with the corresponding cross references between existing and new codes;
deleted codes for which there are no corresponding new codes; and
codes for entirely new services that require pricing. The Division will list these codes and apply individual consideration (I.C.) reimbursement for these codes until appropriate rates can be developed.
14.02: General Definitions Confirmatory (Additional Opinion) Consultation. When the consulting physician or dentist is aware of the confirmatory nature of the opinion that is sought (e.g., when a patient requests a second/third opinion on the necessity or appropriateness of a recommended medical treatment or surgical procedure).
Consultation. A type of service provided by a physician or dentist whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or dentist or other appropriate source. A physician consultant may initiate diagnostic and/or therapeutic services.
The request for a consultation from the attending physician or dentist or other appropriate source and the need for consultation must be documented in the patient's medical record. The consultant's opinion and any services that were ordered or performed must also be documented in the patient's medical record and communicated to the requesting physician or other appropriate source.
Any specifically identifiable procedure (i.e., identified with a specific HCPCS code) performed on or subsequent to the date of the initial consultation should be reported separately.
If a consultant subsequently assumes responsibility for management of a portion or all of the patient's condition(s), the consultation codes should not be used.
Dental Enhancement Fee. D9450 or case presentation; detailed and extensive treatment planning is a dental enhancement fee for Community Health Centers and Hospital Licensed Health Centers who have signed an agreement with MassHealth. This code is used as a Dental Enhancement Fee per Dental User. This code may be billed when other dental procedures are performed on the same day and can only be billed once per dental user per day.
Division: The Division of Health Care Finance and Policy, established under M.G.L. c. 118G.
Eligible Provider. A provider of dental services who meets such conditions of participation as have been or may be adopted from time to time by a governmental unit purchasing such services and:
(a) Dentists registered by the Massachusetts Board of Registration in Dentistry in accordance with the provisions of M.G.L. c. 112; or
(b) Authorized governmental, nonprofit or charitably incorporated dental clinics not involved with teaching dental students; or
(c) Authorized dental clinics that wholly or partially derive support from Title V funds under the Social Security Act; or
(d) Teaching dental clinics operated by dental education institutions; or
(e) Qualified physicians, physician assistants, nurse practitioners, registered nurses, and licensed practical nurses who provide D1206 therapeutic application Fluoride Varnish for moderate to high caries risk patients in accordance with the applicable MassHealth program regulations; or
(f) Public health dental hygienists who are certified by the Massachusetts Board of Registration in Dentistry and provide services in public health settings that include schools, long-term nursing facilities, medical facilities and shelters.
Established Patient. A patient who has received professional services from the physician or dentist within the past three years.
Evaluation and Management (E/M) Services. . The E/M section is divided into broad categories such as office visits, hospital visits and consultations. Most of the categories are further divided into two or more subcategories of E/M services. For a full discussion of these services, refer to the most current Physician’s Current Procedural Terminology (CPT) Handbook.
Governmental Unit. The Commonwealth, any department, division, agency board, or commission of the Commonwealth, and any political subdivision of the Commonwealth.
Levels of E/M Services. Within each category or subcategory of E/M service, there are three to five levels of E/M services available for reporting purposes. Levels of E/M services are not interchangeable among the different categories or subcategories of service.
The levels of E/M services include examinations, evaluations, treatments, conferences with or concerning patients, preventive pediatric and adult health supervision and similar medical services. The levels of E/M services encompass the wide variations in skill, effort, time, responsibility and medical knowledge required for the prevention or diagnosis and treatment of illness or injury and the promotion of optimal health. Each level of E/M services may be used by all physicians or dentists. Coordination of care with other providers or agencies without a patient encounter on that day is reported using the case management codes. For a full discussion of the levels of E/M services, please refer to the most current CPT handbook.
New Patient. A patient who has not received any professional services from the physician or dentist within the past three years.
Publicly Aided Individual. A person who receives medical or dental care and services for which a governmental unit is liable, in whole or in part, under a statutory program of public assistance.
14.03: General Rate Provisions and Maximum Fees (1) Rate Determination. Rates of payment for authorized dental services to which 114.3 CMR 14.00 applies will be the lower of:
(a) The eligible dentist provider's usual fee to patients other than publicly-aided individuals or industrial accident patients; or
The fees listed in 114.3 CMR 14.04, 14.05, 14.06.
Early Periodic Screening, Diagnosis and Treatment (EPSDT). Division of Medical Assistance regulation 130 CMR 420.421 states that dental services provided to members under age 21 must comply with all applicable requirements for Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services set forth in Division of Medical Assistance regulation 130 CMR 450. 140-149.
Individual Consideration (I.C.). Non-listed procedures and dental procedures designated I.C. are individually considered items. Determination of appropriate payment for procedures designated I.C. will be in accordance with the following standards and criteria:
(b) Degree of skill required in the procedure performed;
(c) Severity and/or complexity of the patient's dental disease or condition;
(d) Policies, procedures and practices of other third-party purchasers of dental services, both governmental and private;
(e) Should an eligible provider believe that any such procedure merits a higher fee than recommended, the provider may submit the prescribed claim form with supporting documentation. Such claims will be individually processed.
Prior Approval. A number of procedures require authorization of the appropriate purchasing agency prior to the rendering of service and before payment will be made. Providers should refer to the appropriate purchasing agency manual before providing services.
14.04: Allowable Fees: Anesthesia Services (Hospital) Reimbursement of anesthesia services is set forth in 114.3 CMR 16.00: Surgery and Related Anesthesia Services.
14.05: Allowable Fees: Non-Hospital Services
Periodic oral evaluation - established patient
Limited oral evaluation - problem focused
Oral evaluation for a patient under three years of age and counseling with primary caregiver
Comprehensive oral evaluation - new or established patient
Detailed and extensive oral evaluation - problem focused, by report
Re-evaluation - limited, problem focused (established patient; not postoperative visit)
Comprehensive periodontal evaluation - new or established patient