Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street
Boston, MA  02111
www.mass.gov/dma	
		MassHealth
		Dental Bulletin 26
		March 2002

	TO:	Dental Providers Participating in MassHealth

	FROM:	Wendy E. Warring, Commissioner

	RE:	Important Information About Special Circumstances and Dental Group Practices

Purpose	You recently received Transmittal Letter DEN-59 with a copy of the Division’s revised regulations (130 CMR 420.000) enacting changes to the MassHealth dental program, effective March 15, 2002.  These changes eliminated some dental services for adult members unless the Division approves the member for Special Circumstances (SC) designation.  

This bulletin provides important information that you should know about SC, including:

1)	Your need to submit a request for prior authorization (PA) for SC designation for any adult member who meets the Division’s criteria for SC, as described in 130 CMR 420.410(D)(1).  
2)	There is no deadline for applying for SC designation for any of your patients who meet the above criteria.
3)	Members approved for SC designation will be eligible to receive, as of the date of the approval, those dental services covered prior to March 15, 2002.
4)	Specifics about:

•	the procedures you need to follow to have a member approved for SC designation;
•	the difference between a PA for SC designation and a service-specific PA;
•	the appropriate PA number to use when billing different situations; and
•	how you may apply and qualify your practice to be designated as an Adult Limited Practice (ALP).  ALP designation would provide you with a streamlined method for requesting PA for SC designation for your adult patients with severe, chronic disabilities who meet the Division’s criteria for SC designation as described in 130 CMR 420.410(D)(1)(a).

	

Purpose	In addition, this bulletin provides information about a change in the PA 
(cont.)	process for dental group practices.

Special Circumstances	Unless your practice is designated as an ALP, you must submit a 
Documentation	completed PA form (PA-1) that includes a clear written statement signed by the member’s physician or primary care clinician (PCC), in accordance with 130 CMR 420.410(D)(2), for any member to be considered for SC designation.  Please note that this is the same PA form that you currently use for submitting dental service-specific requests.

Unless your practice is designated as an ALP, the physician or PCC must include with the PA request for SC designation, a description of the member’s disability or clinical condition, including but not limited to, the member’s specific diagnosis and expected prognosis, and 

(1)	whether, and specifically why, the member’s disability results in the member’s inability to maintain oral hygiene (a physician, PCC, or you may document this requirement); or
(2)	a description of the member’s clinical condition, which has advanced to a stage where an infection resulting from oral disease would likely be life-threatening (only a physician or PCC may document this requirement).

Prior Authorization	PA Numbers
Requests
(1)	Group Practices

You may now submit PA requests under your group practice number for any dental service or SC designation.

	(2)	Special Circumstances Designation

•	Unless your practice is designated as an ALP, you must submit an appropriately completed, separate PA form on behalf of each member for whom you are requesting SC designation.
•	If your practice is designated as an ALP, you should follow the alternative process for requesting SC designation for your patients who meet the Division’s criteria for SC designation, as described later in this bulletin under “ALP Documentation.”
•	Your request for a PA for SC designation may not include any service-specific requests for the member.

	

Prior Authorization 	    The Division will issue a PA number to each member whose 
Requests 		PA request for SC designation was approved.  This PA 
(cont.)		number will be specific to the member and the individual or group practice provider whose provider number is entered in block 3 of the PA form.
		Any PA request approved for SC designation will be valid for a period of up to three years from the date of the Division’s approval.

		(3) Service-Specific Requests

•	You must submit an appropriately completed PA form for any service that requires a PA, even if the member has SC designation.
•	You may request one or more dental services on the service-specific PA request, unless the regulations described in 130 CMR 420.000 require a separate submission.
•	Your request for PA for a specific service may not include a request for SC designation for the member.
•	If the Division approves the service-specific PA request, it will issue you a PA number for that service that is specific to that member and the individual or dental group practice whose provider number is entered in block 3 of the PA form.
•	Any PA request approved for a specific service will be valid for a period of up to one year from the date of the Division’s approval.

PA Decision Notices

(1)	Approvals 

•	If your PA request for SC designation is approved, the Division will send you and the member written notification.
•	Notices about approved SC designations will include authorization for those ranges of service codes that are covered only for adult members with SC designation.  
•	All service limitations and regulatory requirements continue to apply to all services delivered to SC members.

(2)	Denials 

•	If your PA request for SC designation is denied, the Division will send you and the member notice of the denial and the reason for this decision. 
•	The member will also receive notice of the right to appeal the decision to the Division’s Board of Hearings.

	

Prior Authorization		Expiration Dates
Requests
(cont.)	    In the approval notice, the Division will also give you the 
expiration date for each PA granted.
•	You need to track the expiration date for each PA to ensure it remains valid.

				PA Instruction Correction

•	Transmittal Letter DEN-59 instructed you to enter “Special Circumstances” or “SC” in block 13 of the PA form when requesting SC designation for any member.  You should have been instructed to enter this information in block 12.
•	Division references in this bulletin to any specifically numbered block on the PA form refer to the most recently revised version (10/01) of the PA form.

Billing	Group Practices

•	You must continue to complete claim form no. 11 according to the billing instructions in Subchapter 5 of the Dental Manual.  Your group practice provider number must be listed in Item 2, the servicing provider number in Item 5, and the PA number in 
Item 27.
•	You must inform the Division’s Provider Enrollment Unit of any new dental providers who become part of or leave your group practice.

	When to Use the SC PA Number

If you provide an adult dental service covered only for members with SC designation, and the specific service does not require a PA, you must write the member’s PA number for SC designation on a claim form no. 11 for payment for that service.

When to Use the Service-Specific PA Number

If you provide an adult dental service covered only for members with SC designation, and the specific service requires a PA, you must write the PA number for the specific service on a claim form no. 11 for payment for that service.  DO NOT include the member’s PA number for SC designation.

For more detailed information about billing, please refer to Transmittal Letter DEN-59, dated March 2002.

	

Adult Limited Practice	Application for ALP

•	You may apply to the Division for your practice to be designated as an ALP.  To qualify as an ALP, your adult dental practice must be primarily limited to disabled patients who meet the Division’s criteria for SC designation, as described in 130 CMR 420.410(D)(1)(a).
•	You may apply at any time to be designated as an ALP.
•	To apply, you must submit the following:

(1)	a copy of your practice’s criteria for disability that meet the Division’s criteria for SC designation, as described in 130 CMR 420.410(D)(1)(a); and
(2)	an estimate of the total number of adult patients in your practice and, of those, the number of patients with SC designation you expect to serve.

•	Send your ALP application to:

		Division of Medical Assistance
		Dental Program Manager
		600 Washington Street
		Boston, MA  02111

ALP Decision

•	 The Division will inform you in writing of its decision about your practice’s ALP designation and what you must do to obtain a PA number for each member who meets the Division’s criteria for SC designation.
•	Until the Division informs you of its decision, you must follow the process for requesting member-specific SC designation as described in 130 CMR 420.410(D)(2).
•	The Division will make its best effort to notify you in writing of its decision about your ALP application within 10 business days of receipt of the application.

	ALP Documentation

•	ALP designation does not necessarily mean that all patients in your dental practice qualify for SC designation.  ALPs need to determine which patients meet SC criteria.
•	If the Division approves your ALP application, you will not need to submit a separate PA request or the required medical documentation for each of your adult patients with disabilities who meet the Division’s criteria for SC designation, as described in 
130 CMR 420.410(D)(1)(a).

	

Adult Limited Practice		   If approved as an ALP, you must submit to the Division prior to 
(cont.)		billing, a list that includes, but is not limited to:

(1)  the name, MassHealth recipient identification number, and date of birth for only those patients who 
specifically meet the Division’s criteria for SC designation, as described in 130 CMR 420.410(D)(1)(a);
(2)  your name or, if applicable, your group practice’s name, and individual or group practice MassHealth provider number; and
(3)	in the case of a group practice, the names and provider numbers for each dentist in the group practice.

•	When a new patient meets the Division’s criteria for SC designation, you must submit the information requested in (1) above for the member to the Division’s Dental Program Manager.
•	You must maintain in the medical record of each adult patient included in the above list and any updates to the list, evidence that each patient on the list meets the Division’s criteria for SC designation, as described in 130 CMR 420.410(D).

Web Site	Information about the revised dental regulations is available on the Division’s Web site at www.mass.gov/dma.  Information about billing for 
	SC can be found in Transmittal Letter DEN-59, dated March 2002, which is also available on the Web site.

Questions	If you have any questions about the information in this bulletin, please call MassHealth Provider Services at 617-628-4141 or 1-800-325-5231.