Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MassHealth Dental Bulletin 38 June 2008 TO: Dental Providers Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: Clarification of Dental Policy for Covered Services and Conditions of Payment Background MassHealth recently revised the dental regulations at 130 CMR 420.000, effective January 1, 2008 (see Transmittal Letter DEN-80). The purpose of this letter is to clarify the dental regulations regarding certain covered services and the conditions of payment. Limited Oral Evaluation – Problem Focused MassHealth pays for comprehensive, periodic, and limited oral evaluations. A limited oral evaluation or reevaluation is performed by the provider to diagnose and determine the treatment for a specific oral health problem (130 CMR 420.422(C)). This may require interpretation of information acquired through additional diagnostic procedures. Additional diagnostic procedures are to be billed separately. Typically, members receiving this type of evaluation have been referred for a specific problem or are presented with dental emergencies, such as acute infection. A limited oral evaluation (Service Code D0140) is not covered if performed on the same date of service as a palliative (emergency) treatment of dental pain – minor procedure (Service Code D9110). Crowns, Posts, and Cores, and Fixed Partial Dentures (Bridgework) MassHealth does not cover core buildup as a separate procedure from the post. Complete Dentures, Relines and Rebases Payment for complete dentures includes all necessary adjustments, including relines within six months after the insertion of the denture for members under the age of 21, and within 12 months of the insertion of the denture for members aged 21 or older. MassHealth pays for subsequent relines or rebases once every two years for members under the age of 21 and once every three years for members aged 21 or older (130 CMR 420.428(E)). (continued on next page) MassHealth Dental Bulletin 38 June 2008 Page 2 Removable Partial Dentures 130 CMR 420.428(C) sets forth the circumstances under which MassHealth pays for a removable partial denture. References to teeth that are “missing” include both natural teeth and fixed prosthetic replacements. Orthodontic Services Age Limitation The policy regarding orthodontic services has not changed with the exception that members who qualify for medically necessary orthodontic services must begin the initial treatment for orthodontic services before the member reaches age 21. MassHealth will pay for the continuation of full orthodontic treatment as long as the member remains eligible for MassHealth, provided that the initial treatment started before the member reached age 21 (130 CMR 420.431(A)). Claims for Comprehensive Orthodontic Treatment and Treatment Visits The dental regulations at 130 CMR 420.431 will be amended to clarify the following: • The payment for comprehensive orthodontic treatment (Service Code D8080) includes pre-orthodontic workup (orthodontic consultation), records, photographic prints, models, radiographs, and initial banding. This service is billed separately. • The first year of treatment visits (Service Code D8670) is billed in four quarters. The payments remitted for the quarterly visits are not included in the payment for the initial orthodontic banding. • MassHealth requires that its members receive treatment visits in at least eight out of 12 months in an authorized year of treatment before billing for the next treatment year. • The provider may bill for a quarter if they have seen the member once in that quarter. Questions If you have any questions about the information in this bulletin, please contact MassHealth Dental Customer Service at 1-800-207-5019, or e- mail your inquiry to inquiries@masshealth-dental.net.