Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MassHealth Transmittal Letter DEN-86 September 2010 TO: Dental Providers Participating in MassHealth FROM: Terence G. Dougherty, Medicaid Director RE: Dental Manual (Correction to Service Code and Description for D1351) This letter transmits a minor correction to the description for a service code listed in Subchapter 6 of the Dental Manual. This change in the description was overlooked in the recently issued Transmittal Letter DEN-85. Changes to Subchapter 6 ? Service Codes and Descriptions D1351 Sealant, per tooth (primary or permanent first, second, and third noncarious, nonrestored molars) The above revision is effective with dates of service on or after October 1, 2010. If you have any questions about the information in this transmittal letter, please contact MassHealth Dental Customer Service at 1-800-207-5019, or e-mail your inquiry to inquiries@masshealth-dental.net. NEW MATERIAL (The pages listed here contain new or revised language.) Dental Manual Pages 6-3 and 6-4 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Dental Manual Pages 6-3 and 6-4 ? transmitted by Transmittal Letter DEN-85 ? Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-3 Dental Manual Transmittal Letter DEN-86 Date 10/01/10 MassHealth pays for the dental services as described in MassHealth regulations at 130 CMR 420.000 and 450.000. A dental provider may request prior authorization for any medically necessary service payable in accordance with the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) provisions set forth in 130 CMR 450.144, 42 U.S.C.1396d(a), and 42 U.S.C. 1396d(r)(5) for a MassHealth Standard or CommonHealth member under age 21. This applies even if the service is not listed in Subchapter 6 of the Dental Manual. For each dental service code, the description indicates any limitations, such as age and frequency, and if prior authorization is required for the member. Oral and maxillofacial surgeons must submit all requests for prior authorization and claims containing Current Procedural Terminology (CPT) codes directly to MassHealth rather than to any third party administrator or other MassHealth vendor, as described in 130 CMR 420.000. Public health dental hygienists may claim payment for Service Codes D1110, D1120, D1203, D1204, D1206, D1351, D4341, D4342, D9110, and D9410. 601 Explanation of Abbreviations and Report Requirements The following abbreviations are used in Subchapter 6 with certain services that may require special reporting, as described below. (A) ?PA? indicates that service-specific prior authorization is required (see 130 CMR 420.410). The provider must include in any request for prior authorization sufficiently detailed, clear information documenting the medical necessity of the service requested and, where specified, the information described in this Subchapter 6. The MassHealth agency may require any additional information it deems necessary. If prior authorization is not required, the provider must maintain in the member?s dental record, all information necessary to disclose the medical necessity for the services provided. Pursuant to 130 CMR 420.410(B)(3) prior authorization may be requested for any exception to a limitation on a service otherwise covered for that member. (For example, MassHealth limits prophylaxis to two per member per calendar year, but will pay for additional prophylaxis for a member within a calendar year if medically necessary.) (B) ?IC? indicates that the claim will receive individual consideration to determine payment. A descriptive report must accompany the claim (see 130 CMR 420.412). Reports must accompany the claim and be sufficiently detailed to enable the MassHealth agency to assess the extent and nature of the services provided and include the following where applicable: (1) the amount of time required to perform the service; (2) the degree of skill required to perform the service; (3) the severity and complexity of the member?s disease, disorder, or disability; and (4) any extenuating circumstances or complications. (C) ?SP? indicates that the procedure is commonly performed as part of a total service and does not usually warrant a separate fee. The procedure must be performed separately to receive the separate fee (see 130 CMR 420.413). (D) ?By report? in the service code description column indicates that the provider must include with the claim a narrative documenting the medical necessity for the procedure. ? Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-4 Dental Manual Transmittal Letter DEN-86 Date 10/01/10 604 Service Codes and Descriptions: Preventive Services (cont.) Service Code Service Code Description Covered Under Age 21? CoveredDDS Clients Aged 21 and Older? Covered Aged 21 and Older? Prior Authorization Requirements, Report Requirements, and Notations D1204 Topical application of fluoride, adult (prophylaxis not included) No* No* * exception for members who have a medical or dental condition that significantly interrupts the flow of saliva?PA required. See 601(A) above and 130 CMR 420.424(B)(1)(b). D1206 Topical fluoride varnish; therapeutic application for moderate to high caries risk patients Yes No No Other Preventive Services D1351 Sealant, per tooth (primary or permanent first, second, and third noncarious, nonrestored molars) Yes No No Space Maintenance (Passive Appliances) D1510 Space maintainer, fixed-unilateral Yes No No D1515 Space maintainer, fixed-bilateral Yes No No D1520 Space maintainer, removable-unilateral Yes No No D1525 Space maintainer, removable-bilateral Yes No No D1550 Recementation of space maintainer Yes No No 605 Service Codes and Descriptions: Restorative Services See 130 CMR 420.425 for service descriptions and limitations. Service Code Service Code Description Covered Under Age 21? CoveredDDS Clients Aged 21 and Older? Covered Aged 21 and Older? Prior Authorization Requirements, Report Requirements, and Notations Amalgam Restorations (Including Polishing) D2140 Amalgam?one surface, primary or permanent Yes Yes No D2150 Amalgam, two surfaces, primary or permanent Yes Yes No D2160 Amalgam, three surfaces, primary or permanent Yes Yes No