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Serving the MassHealth Program*MassHealth Dental ProgramCommonwealth of MassachusettsJanuary 1, 2022Office Reference Manual465 Medford StreetBoston, MA www.masshealth-dental.net.MassHealth Dental Program March 3, 2022Current Dental Terminology American Dental Association. All Rights Reserved.
MassHealth Dental Program2MassHealth Dental ProviderQuick Reference Directorywww.masshealth-dental.netServing the MassHealth Program*Provider ServicesPhone NumberE-mail AddressMailing AddressMember Eligibility & netMassHealth-Eligibility & BenefitsP.O. Box 2906Milwaukee, WI 53201-2906TDD (Hearing Impaired)MassHealth Medical Customer Service(Oral Surgeons)MassHealth Medical Eligibility & BenefitsMassHealth Medical Fax 4providersupport@masshealth.netAuthorizationsPrior Authorizations (PA)1.800.207.5019MassHealth Dental – PAP.O. Box 2906Milwaukee, WI 53201-2906ClaimsPaper Claims Submission1.800.207.501990 Day Waiver/Final Deadline equestMassHealth Dental – ClaimsP.O. Box 2906Milwaukee, WI 53201-2906MassHealth Dental – 90 DayWaiver/Final Deadline Appeals465 Medford StreetP.O. Box 9708Boston, MA 02114-9708Electronic ClaimsEDI Claims Submission (837Transactions) and Remittance a Website atwww.masshealth-dental.netVia ClearinghousePayer ID MassHealth Dental – ClaimsP.O. Box 2906Milwaukee, WI 53201-2906Provider Complaints and FraudProvider ComplaintsFraud HotlineMassHealth Dental – ClaimsP.O. Box 2906Milwaukee, WI 53201-2906***MassHealth offers you the ability to submit HIPAA-compliant claims to: www.masshealth-dental.net. You may also submit claims through anapproved clearinghouse trading partner. Please contact your software vendor to ensure that theMassHealth Dental Program is listed as a payer. The MassHealth is CKMA1.For greater detail, please contact Customer Service at: 1.800.207.5019 or your Provider Relations Representative.Provider EnrollmentProvider l.netMassHealth Dental- PECP.O. Box 2906Milwaukee, WI comsusan.evers@dentaquest.comContract DirectorProvider Relations RepresentativeProvider Relations RepresentativeProvider Relations RepresentativeMassHealth Team at DentaQuestTracy Gilman (Chase)Daniel ArchambaultKeishia LopezSusan EversThank you to all providers who currently participate with MassHealth. Your commitment to serving your community and providing the bestpossible care to our members is greatly appreciated. Our goal is to continue to raise the bar in terms of customer service. Please reach our any timeyou have concerns, suggestions, or praise, as we continue to work together to promote oral health within the Commonwealth of Massachusetts.Sincerely,The MassHealth Team at DentaQuest*DentaQuest is the subcontractor to Dental Service of Massachusetts, Inc.MassHealth Dental Program March 3, 2022Current Dental Terminology American Dental Association. All Rights Reserved.
MassHealth Dental Program3MassHealth Dental ProgramStatement of Members’ Rights and ResponsibilitiesMissionThe mission of the MassHealth Dental Program is to expand access to high-quality and compassionate oral health services.The MassHealth Dental Program is committed to ensuring that all members are treated in a manner that respects theirrights and acknowledges its expectations of members’ responsibilities.Members Rights & ResponsibilitiesMembers shall have the rights and responsibilities to:1.Receive up-to-date information about the MassHealth Dental Program, the services the MassHealth DentalProgram provides, the participating providers and dental offices, as well as members’ rights and responsibilities.2.Privacy and to be treated with respect and recognition of their dignity when receiving dental care.3.Participate with caregivers in the decision-making process surrounding their health care.4.Be fully informed about the appropriate and medically necessary treatment options for any condition, regardlessof the coverage or cost for the care discussed. Members also have the right to request a second opinion.5.Voice a complaint against the MassHealth Dental Program, or any of its participating dental providers, for any ofthe care provided by these providers when their performance has not met the member’s expectations.6.Appeal any denial decision resulting from a prior authorization request related to patient care and treatment.Members may appeal directly to the Board of Hearings.7.Make recommendations regarding the MassHealth Dental Program members’ rights and responsibilities policies.Likewise:8.Provide, to the best of their abilities, accurate information that the MassHealth Dental Program and itsparticipating dentists need to receive the highest quality of healthcare services.9.Closely follow the treatment plans and instructions for the care that they have agreed upon with their dentalpractitioners.10.Make every effort to keep dental appointments and to notify the dental practitioner as far in advance as possibleif an appointment cannot be kept.11.Participate in understanding their dental problems and developing mutually agreed upon treatment goals to thedegree possible.MassHealth Dental Program March 3, 2022Current Dental Terminology American Dental Association. All Rights Reserved.
MassHealth Dental Program4MassHealth Dental ProgramStatement of Provider Rights and ResponsibilitiesProviders shall have the right to:1.Communicate with members regarding dental treatment options.2.Recommend a course of treatment to a member, even if the course of treatment is not a covered service orapproved by the MassHealth Dental Program.3.Supply accurate, relevant, and factual information to any member in connection with an appeal or complaint filedby the member.4.Provide feedback on policies, procedures or decisions made by the MassHealth Dental Program5.Charge an eligible MassHealth member for dental services that are not covered services only if the memberknowingly elects to receive the services as a private-pay patient and enters into an agreement in writing to pay forsuch services prior to receiving them. Non-covered services include services not covered under the MassHealthDental Program (except prior authorizations that are requested for non-covered services for members under age21) and services for which pre-authorization has been denied and deemed not medically necessary6.Be informed in a timely manner of the status of their credentialing or re-credentialing application, upon request.7.Determine the number of MassHealth members you wish to welcome into your practice.Providers have the responsibility to:1.Protect the patients’/members’ rights to privacy.2.Notify the MassHealth Dental Program of any changes in their practice information, including location, telephonenumber, limits to participation, providers joining or leaving the practice, etc. within 14 days of change.3.Hold the MassHealth members harmless and to not bill any member for services if the services are not covered asa result of any error or omission by the provider.4.Adhere to the MassHealth Provider Contract and regulations.*The MassHealth Dental Program makes every effort to maintain accurate information in this manual; however, the MassHealth DentalProgram and its administrator will not be held liable for any damages directly or indirectly due to typographical errors. Please contactus should you discover an error.MassHealth Dental Program March 3, 2022Current Dental Terminology American Dental Association. All Rights Reserved.
MassHealth Dental Program5Office Reference Manual Table of ContentsSectionPageWhat is the MassHealth Dental Program? . 71.00Provider Services . 71.1Dedicated Call Center for Dental Providers . 71.2Provider Training . 71.3Provider Newsletters. 71.4Customer Web Portal . 71.5Specialist Referral Process . 81.6Provider Directory . 82.00Eligibility Verification Procedures . 92.1MassHealth Dental Program Eligibility . 92.2MassHealth Dental Program Eligibility Systems . 93.00Authorization for Treatment . 113.1Prior Authorization Request for CPT Codes. 113.2Covered Services Requiring Authorization . 113.3Authorization for Operating Room (OR) Cases . 123.4Payment for Non-Covered Services . 123.5Electronic Attachments . 133.6Member Transportation . 133.7Orthodontia . 143.8Transfer or Release of Authorization . 144.00Claim Submission Procedures (Claim Filing Options) . . .154.1Electronic Claim Submission through direct data entry . 154.2Electronic Claim Submission via Clearinghouse . 154.3Paper Claim Submission . 154.4Behavior Management . 164.5Third Party Liability (TPL) . 174.6Filing Limits . 184.7Remittance Information.194.8Claim Submission and Payment for Operating Room (OR) Cases . 194.9Rural Add-On Payments . 194.10Claim Submission for CPT Codes 205.00Health Insurance Portability and Accountability Act (HIPAA) . 206.00Complaints and Appeals . 217.00Utilization Management Program. 277.1Introduction. 277.2Community Practice Patterns . 277.3Evaluation . 277.4Results . 287.5Fraud and Abuse. 288.00Quality Improvement Program . 289.00Credentialing . 299.1Appeal of Credentialing Committee Recommendations. 299.2Discipline of Providers. 299.3Procedures for Discipline and Termination . 299.4Re-credentialing . 2910.00 The Patient Record - See MassHealth Regulations at 130 CMR 420.414 . 3010.1Organization . 3010.2Content-The Patient Record Must Contain the Following . 3010.3Compliance . 32MassHealth Dental Program March 3, 2022Current Dental Terminology American Dental Association. All Rights Reserved.
MassHealth Dental Program611.00Patient Recall System . 3311.1Recall System Recommendation . 3312.00Intervention Services Program . 3412.1Dedicated Intervention Specialists . 3412.2Appointment Assistance . 3412.3Non-Compliant Members . 3412.4Office Compliance Verification Procedures . 3413.00Radiology Requirements . .3514.00Preventive Health Guidelines – Ages 0-20 Years . 3615.00Clinical Criteria . 3815.1Dental Extractions . 3915.2Cast Crowns . 3915.3Endodontic Treatment . 4015.4Stainless Steel Crowns . 4015.5Operating Room (OR) Cases . 4115.6Removable Prosthodontics (Full and Partial Dentures) . 4115.7Determination of a Non-Restorable Tooth . 4315.8Criteria for General Anesthesia and Intravenous (IV) Sedation . 4315.9Periodontal Treatment . 4416.00Orthodontia . 4516.1Eligibility for Orthodontic Treatment . 4516.2Authorization for Treatment – Comprehensive Orthodontia . 4516.3Authorization Determination . 4816.4Continuation of Care . 5116.5Interceptive Orthodontic Treatment . 5117.00Limited Product. 5417.1The Children’s Medical Security Plan . . 54Additional Resources .56APPENDIX A General Definitions .A-1APPENDIX B Sample FormsAuthorization Form for Comprehensive Orthodontic Treatment .B-1Medical Necessity Narrative.B-2Handicapping Labio-Lingual Deviation Index Scoring Instructions.B-3Orthodontic Continuation of Care Form.B-4Dental Claim Form with Instructions.B-5Void Request Form .B-6Initial Clinical Exam.B-7Recall Examination Form.B-8Medical and Dental History.B-9Provider Change Form.B-10APPENDIX C Quick Reference FlyersThird Party Liability .C-1Corrective Action for Denied Claims .C-2Corrective Action for Incorrectly Paid Claims .C-3Overpayments on Claims .C-4APPENDIX DCovered Services (See Exhibits A-F)Eligible Services . .D-1Orthodontics & Radiographs . D-2Exhibit AMassHealth Dental Program (under 21) Covered Services (Orthodontic)Exhibit BMassHealth Dental Program (21 and older) Regular Covered ServicesExhibit CMassHealth Dental Program (21 and older) DDS Covered ServicesExhibit DMassHealth – Limited (Emergency Coverage Only)Exhibit EChildren’s Medical Security PlanExhibit FMassHealth Dental Program (Under 21) DDS Covered ServicesMassHealth Dental Program March 3, 2022Current Dental Terminology American Dental Association. All Rights Reserved.
MassHealth Dental ProgramWhat is the MassHealth Dental Program?The MassHealth Dental Program is based upon Commonwealth of Massachusetts regulations governing dental servicesfound in 130 CMR 420.000 and 450.000. All dental providers participating in MassHealth must comply with theseregulations. Please refer to the MassHealth website at WWW.MASS.GOV for complete Dental and All Provider Manualswhich contain the regulations. If there is a conflict between the Office Reference Manual and the regulations, theregulations take precedence in every case.The goals of the MassHealth Dental Program are to: 1.0Improve member access to quality dental careImprove oral health and wellness for MassHealth membersIncrease provider participation in the MassHealth Dental Program networkStreamline program administration, making it easier for providers to participateCreate a partnership between MassHealth and the Dental CommunityProvider Services1.1Dedicated Call Center for Dental ProvidersThe MassHealth Dental Program offers Participating MassHealth Dental provider’s access to CustomerService Representatives who specialize in areas such as: Eligibility, covered services and authorizationsClaims, andIntervention ServicesYou can reach customer service at 1.800.207.5019.1.2Provider TrainingThe MassHealth Dental Program offers free provider training sessions periodically throughout theCommonwealth of Massachusetts. These sessions include important information such as: claimssubmission procedures, prior-authorization criteria, how to access the MassHealth Dental Program’sclinical personnel, etc. In addition, providers can contact a MassHealth Provider RelationsRepresentative for assistance, or to request a personal, in-office visit at 1.800.207.5019.1.3Provider NewslettersThe MassHealth Dental Program publishes annual provider newsletters that include helpful informationof interest to providers. Newsletters are available via the MassHealth provider web portal in thedocument section at www.masshealth-dental.net.1.4Provider Web PortalThe MassHealth Dental Program offers self-service options through the Internet that allow ParticipatingMassHealth Dental Program provider’s access to several helpful options including: Member eligibility and verificationSubmitting Prior AuthorizationsClaims submissionView claim statusCreate claim tracking reportsSubmission of attachmentsSubmit complaints, grievances, reconsiderations, and general inquiriesLog broken appointmentsAccess important Forms, trainings, and the Office Reference ManualFor more information, contact the MassHealth Dental Program at 1.800.207.5019.MassHealth Dental Program March 3, 2022Current Dental Terminology American Dental Association. All Rights Reserved.7
MassHealth Dental Program1.58Specialist Referral ProcessA member requiring a referral to a dental specialist can be referred directly to any specialistparticipating in the MassHealth Dental Program without authorization from the MassHealth DentalProgram. The dental specialist is responsible for obtaining prior authorization if necessary, for coveredservices according to Exhibits A-F of this Manual. Providers who are unfamiliar with the MassHealthDental Program specialty network or need assistance locating a certain specialist can contact theMassHealth Dental Program’s Provider Relations Department at 1.800.207.5019.1.6Provider DirectoryThe MassHealth Dental Program publishes an on-line provider directory for MassHealth members called“Find a Provider. This provider directory includes: provider name, practice name (if applicable), officeaddress (es), telephone number(s), provider specialty, office hours (if available), handicap accessibility,age range of accepted patients, languages spoken (if available), and any other limitations of which theMassHealth Dental Program is aware. You can find the Find a Provider directory on the MassHealthwebsite at www.masshealth-dental.net.It is very important that providers notify the MassHealth Dental Program of any changes in practiceinformation. The Provider Change Form found in the appendices should be completed and faxed to theMassHealth Dental Program at 1.262.241.4077 within 14 days of any change or submitted via thecontact us link on the provider web portal at www.masshealth-dental.net.1.7Translation & Interpreter ServicesDoes our office need to pay and/or provide translation or interpreter services?All MassHealth participating providers are responsible for the reasonable coordination and cost ofproviding translation services. Reasonable steps may include written translations of documents, or oral language assistance from aqualified interpreter, either in-person or using remote communication technology. MassHealth does not reimburse for translation or interpretation services and the member may not becharged given it is a state and federal requirement. Where can I learn more?To learn more please visit the following sources: lep-bulletin-5-15-2020-english.pdf (hhs.gov) ions-and-answers https://www.ada.org/en/search-results#q translation%20and%20interpreter&t all&sort relevancyWhat resources are available to my practice?Resources from MassHealth to connect with interpreters via phone (for a fee to be paid by the provider’spractice):Non-emergencies:Voice: 617-740-1600, 8:45 a.m. to 5:00 p.m.TTY: 617-740-1700 TTY, 8:45 a.m. to 5:00 p.m.Legal emergencies: Voice AND TTY: 800-249-9949, 24 hours a day, 7 days a weekMassHealth Dental Program March 3, 2022Current Dental Terminology American Dental Association. All Rights Reserved.
MassHealth Dental Program2.09Eligibility Verification Procedures2.1MassHealth Dental Program EligibilityDental services are covered for MassHealth eligible members as specified in 130 CMR 450.105 and420.403. Members will receive a MassHealth ID card for services, including dental.*Please note that MassHealth Limited members are covered for emergency services only. [130 CMR450.105 (G)]. This information is displayed as Coverage Type on the Provider Web Portal and isprovided via eligibility verification using the IVR.2.2MassHealth Dental Program Eligibility SystemsParticipating MassHealth Dental providers may access member eligibility information 24 hours a day, 7days a week through the MassHealth Dental Program’s Interactive Voice Response (IVR) system orthrough the provider web portal via the dentist tab and link located at www.masshealth-dental.net. Theeligibility information received from either system is the same information available by callingMassHealth Dental Program’s Customer Service Department.Access to Eligibility Information via the Internet:The MassHealth Dental Program’s provider web portal allows providers to verify a member’s eligibilityonline by entering the member’s date of birth, the expected date of service and the member’sidentification number or last name and first initial.The lin
Provider Complaints 1.800.207.5019 inquiries@masshealth-dental.net MassHealth Dental t Claims Fraud Hotline 1.800.237.9139 P.O. Box 2906 Milwaukee, WI 53201-2906
