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
	Nurse Practitioner Bulletin 12
	March 2002

	TO:	Nurse Practitioners Participating in MassHealth

	FROM:	Wendy E. Warring, Commissioner

	RE:	Revisions to the MassHealth Dental Program

Background	Effective March 15, 2002, MassHealth is eliminating some dental benefits for its members aged 21 and older, except for those members for whom a request for prior authorization for “Special Circumstances” designation is submitted to and approved by the Division. MassHealth members with Special Circumstances are generally those with a crucial medical need for dental care, such as members with severe, chronic disabilities who are unable to maintain oral hygiene and those for whom oral disease may be life threatening.  This bulletin is to inform you that you may be asked to provide medical documentation for patients who may meet the Special Circumstances criteria.

Special Circumstances	The revised dental regulations at 130 CMR 420.410(D)(1) specify that to
Criteria	demonstrate Special Circumstances, the member must have

(a)	a severe chronic disability that
(i)	is attributable to a mental or physical impairment or combination of mental or physical impairments; 
(ii)	is likely to continue indefinitely; and
(iii) results in the member’s inability to maintain oral hygiene; or

(b)  a clinical condition (such as human immunodeficiency virus or cancer) that has advanced to a stage where an infection resulting from oral disease would likely be life threatening.

Prior Authorization	The member’s dental provider must submit a prior authorization request for Special Circumstances designation that includes medical documentation signed by the member’s physician or primary care clinician as described below.

	

Documentation	The dental regulations at 130 CMR 420.410(D)(2) require that the prior authorization request for Special Circumstances designation contain a written statement signed by the member’s physician or primary care clinician (on the clinician’s letterhead), clearly describing the member’s disability or clinical condition including, but not limited to, the member’s specific diagnosis and expected prognosis, and

(a)	whether, and specifically why, the member’s disability results in the member’s inability to maintain oral hygiene, or

(b)	whether the member’s clinical condition has advanced to a stage where an infection resulting from oral disease would likely be life threatening, including reference to specific diagnostic evidence.

Inability to Maintain	For the purposes of 130 CMR 420.410(D)(1)(a) and (2)(a), “inability to 
Oral Hygiene	maintain oral hygiene” means

(a)	The member is unable to

(1)	independently or with assistance (providing that such assistance actually is available), brush and floss his or her teeth and perform other routine acts of personal oral hygiene; or

(2)	report oral pain; or

(b)	The nature of the member’s disability is such that routine acts of personal oral hygiene are insufficient to maintain such hygiene.

Web site	This provider bulletin, the dental transmittal letter and its attachments, and the dental regulations are available on the Division’s Web site at www.mass.gov/dma/whatsnew/new_IDX.htm.

Questions	If you have any questions, please call MassHealth Provider Services at 617-628-4141 or 1-800-325-5231.