Commonwealth of Massachusetts
MassHealth
Provider Manual Series
Dental Manual
Subchapter Number and Title
Table of Contents
Page vi
Transmittal Letter DEN-90
Date 01/01/13


6.  Service Codes

Introduction	 	6-1
Explanation of Abbreviations and Service Code Requirements 	6-2
Service Codes:  Diagnostic Services 		6 2
Service Codes:  Radiographs 	6-3
Service Codes:  Preventive Services 		6-3
Service Codes:  Restorative Services 		6-4
Service Codes:  Endodontic Services. 		6-7
Service Codes:  Periodontic Services 		6-8
Service Codes:  Prosthodontic (Removable) Services 	6-9
Service Codes:  Prosthodontic (Fixed) Services 		6-11
Service Codes:  Exodontic Services 		6-11
Service Codes:  Orthodontic Services 		6-13
Service Codes:  General Anesthesia and IV Sedation Services	6-18
Service Codes:  Other Services		6-18
Service Codes:  Oral and Maxillofacial Surgery Services		6-20

Appendix A.  Directory 		A-1

Appendix B.  Enrollment Centers 		B-1

Appendix C.  Third-Party-Liability Codes 		C-1

Appendix D.  Handicapping Labio-Lingual Deviations Form 	D-1

Appendix E.  (Reserved)

Appendix F.  (Reserved)

Appendix G.  Utilization Management Program 		G-1

Appendix H.  Admission Guidelines		H-1

Appendix I.  (Reserved)

Appendix U. DPH-Designated Serious Reportable Events That Are Not Provider Preventable Conditions	U-1

Appendix V. MassHealth Billing Instructions for Provider Preventable Conditions		V-1

Appendix W. EPSDT Services:  Medical and Dental Protocols and Periodicity Schedules		W-1

Appendix X.  Family Assistance Copayments and Deductibles		X-1

Appendix Y.  EVS/Codes Messages 		Y-1

Appendix Z.  EPSDT/PPHSD Screening Services Codes 		Z-1