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Serving the MassHealth Program*MassHealth Dental ProgramCommonwealth of Massachusetts(March 1, 2016)Office Reference Manual465 Medford StreetBoston, MA w.masshealth-dental.net.MassHealth Dental Program March 29, 2016Current Dental Terminology American Dental Association. All Rights Reserved.
2MassHealth Dental ProgramMassHealth Dental ProviderQuick Reference DirectoryEffective: January 1, 2013masshealth-dental.netServing the MassHealth Program*Provider ServicesPhone NumberE-mail AddressMailing AddressMember Eligibility & netMassHealth Dental12121 North Corporate ParkwayMequon, WI 53092TDD (Hearing Impaired)MassHealth Medical Customer Service(Oral Surgeons)MassHealth Medical Eligibility & BenefitsMassHealth Medical Fax 4providersupport@masshealth.netAuthorizationsPrior Authorizations (PA)MassHealth Dental – PA12121 North Corporate ParkwayMequon, WI 530921-800-207-5019ClaimsPaper Claims Submission1-800-207-501990 Day Waiver/Final Deadline al.netMassHealth Dental – Claims12121 North Corporate ParkwayMequon, WI 53092MassHealth 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 – Claims12121 North Corporate ParkwayMequon, WI 53092Provider Complaints and FraudProvider ComplaintsFraud HotlineMassHealth Dental – Claims12121 North Corporate ParkwayMequon, WI 53092***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 Dental12121 North Corporate ParkwayMequon, WI aquest.comContract DirectorProvider Intervention SpecialistMember Intervention SpecialistProvider Relations RepresentativeProvider Relations RepresentativeVice President, Network ManagementOutreach CoordinatorMassHealth Team at DentaQuestTracy Gilman (Chase)Felicia MosesAndres FernandezDaniel ArchambaultKeisha LopezMarianne LeahyMegan MackinThank you to all of the 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 29, 2016Current Dental Terminology American Dental Association. All Rights Reserved.
MassHealth Dental Program3MassHealth Dental ProgramStatement of Members’ Rights and ResponsibilitiesThe 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 shall have the rights and responsibilitiesto: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 in order 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 29, 2016Current 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 complaintfiled by the member.4.Provide feedback on policies, procedures or decisions made by the MassHealth Dental Program Charge an eligibleMassHealth member for dental services that are not covered services only if the member knowingly elects toreceive the services as a private-pay patient and enters into an agreement in writing to pay for such services priorto receiving them. Noncovered services include: services not covered under the MassHealth Dental Program(except prior authorizations that are requested for noncovered services for members under age 21) and servicesfor which pre-authorization has been denied and deemed not medically necessary5.Be informed timely of the status of their credentialing or recredentialing application, upon request.6.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,telephone number, 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 29, 2016Current Dental Terminology American Dental Association. All Rights Reserved.
MassHealth Dental Program5Office Reference ManualTable of ContentsSectionPageWhat is the MassHealth Dental Program? . 71.00 Provider Services . 71.01Dedicated Call Center for Dental Providers . 71.02Provider Training. 71.03Provider Newsletters . 71.04Customer Web Portal . 71.05Specialist Referral Process . 81.06Provider Directory. 82.00Eligibility Verification Procedures . 92.01MassHealth Dental Program Eligibility . 92.02MassHealth Dental Program Eligibility Systems . 93.00Authorization for Treatment . 113.01Prior Authorization Request for CPT Codes . 113.02Covered Services Requiring Authorization . 113.03Authorization for Operating Room (OR) Cases . 133.04Payment for Non-Covered Services. 143.05Electronic Attachments . 143.06Member Transportation . 143.07Orthodontia . 153.08Transfer or Release of Authorization . 154.00Claim Submission Procedures (Claim Filing Options) for Claims with Dates of Service on or after July 1, 2012 . 164.01Electronic Claim Submission through direct data entry . 164.02Electronic Claim Submission via upload to www.masshealth-dental.net. . 174.03Electronic Claim Submission on hard media . 174.04Electronic Claim Submission via Clearinghouse . 174.05Paper Claim Submission. 184.06Third Party Liability (TPL) . 184.07Filing Limits. 194.08Remittance Information . 204.09Claim Submission and Payment for Operating Room (OR) Cases . 204.10Claim Submission for CPT Codes . 205.00Health Insurance Portability and Accountability Act (HIPAA) . 216.00Complaints and Appeals . 227.00Utilization Management Program . 237.01Introduction . 237.02Community Practice Patterns . 237.03Evaluation . 237.04Results . 247.05Fraud and Abuse . 248.00 Quality Improvement Program . 259.00 Credentialing. 269.01Appeal of Credentialing Committee Recommendations . 269.02Discipline of Providers . 269.03Procedures for Discipline and Termination . 269.04Recredentialing . 2710.00The Patient Record See MassHealth Regulations at 130 CMR 420.414 . 2810.01Organization . 2810.02Content-The Patient Record Must Contain the Following: . 2810.03Compliance. 31MassHealth Dental Program March 29, 2016Current Dental Terminology American Dental Association. All Rights Reserved.
MassHealth Dental Program611.00Patient Recall System . 3211.01Recall System Recommendation . 3212.00Intervention Services Program . 3312.01Dedicated Intervention Specialists . 3312.02Appointment Assistance . 3312.03Non-Compliant Members . 3312.04Office Compliance Verification Procedures . 3413.00Radiology Requirements . 3514.00Preventive Health Guidelines – Ages 0-20 Years . 3715.00Clinical Criteria . 3815.01Dental Extractions . 3915.02Cast Crowns. 3915.03Endodontic Treatment . 4015.04Stainless Steel Crowns . 4115.05Operating Room (OR) Cases . 4215.06Removable Prosthodontics (Full and Partial Dentures) . 4215.07Determination of a Non-Restorable Tooth . 4415.08Criteria for General Anesthesia and Intravenous (IV) Sedation . 4515.09Periodontal Treatment . 4516.00Orthodontic . 4716.01Authorization for Treatment – Comprehensive Orthodontic . 4716.02Authorization Determination . 4816.03Continuation of Care . 5116.04Interceptive Orthodontic Treatment . 5216.05General Billing Information for Orthodontics . 5217.00Limited Product . 54Additional Resources . 55APPENDIX AGeneral Definitions . A-1APPENDIX BSample FormsAuthorization Form for Comprehensive Orthodontic Treatment . B-1Peer –to-Peer Guidelines . B-6Orthodontic Continuation of Care Form. B-7Dental Claim Form . B-8Instructions for Dental Claim Form . B-9Void Request Form . B-15Initial Clinical Exam . B-16Recall Examination Form . B-17Medical and Dental History. B-18Provider Change Form . B-20APPENDIX CQuick 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 . D-1Exhibit A MassHealth Dental Program (under 21) Covered Services (Orthodontic) . D-2Exhibit B MassHealth Dental Program (21 and older) Regular Covered Services . D-3Exhibit C MassHealth Dental Program (21 and older) DDS Covered Services . D-4Exhibit D MassHealth – Limited (Emergency Coverage Only) . D-5MassHealth Dental Program March 29, 2016Current Dental Terminology American Dental Association. All Rights Reserved.
MassHealth Dental Program7What 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: 1.00Improve 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 Services1.01Dedicated 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 800.207.5019.1.02Provider 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 800.207.5019.1.03Provider NewslettersThe MassHealth Dental Program publishes biannual provider newsletters that include helpfulinformation of interest to providers. Newsletters are available via the MassHealth provider web portal atwww.masshealth-dental.net.To request a paper copy of the MassHealth Dental Program provider newsletter, call MassHealthProvider Services Representative at 800.207.5019.1.04Provider 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 verificationPrior Authorizations Claims submissionMassHealth Dental Program March 29, 2016Current Dental Terminology American Dental Association. All Rights Reserved.
MassHealth Dental Program 8View claim statusCreate claim tracking reportsSubmission of attachmentsMessage customer serviceLog a broken appointmentForms / Office Reference ManualFor more information, contact the MassHealth Dental Program at 800.207.5019.1.05Specialist 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-D of this Manual. Providers who are unfamiliar with the MassHealthDental Program specialty network or need assistance locating a certain specialty can contact theMassHealth Dental Program’s Provider Relations Department at 800.207.5019.1.06Provider DirectoryThe MassHealth Dental Program publishes an on-line provider directory for MassHealth members calledfind 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.It is very important that providers notify the MassHealth Dental Program of any changes in practiceinformation. The Provider Change Form found in Appendix B-25 should be completed and faxed to theMassHealth Dental Program at 262.241.4077 within 14 days of any change.MassHealth Dental Program March 29, 2016Current Dental Terminology American Dental Association. All Rights Reserved.
MassHealth Dental Program2.009Eligibility Verification Procedures2.01MassHealth 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.2.02MassHealth 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 Internet at www.masshealth-dental.net. The eligibility information received from eithersystem is the same information available by calling MassHealth Dental Program’s Customer ServiceDepartment.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 MassHealth Dental Program website is located at www.masshealth-dental.net.To check eligibility, information about the member, provider and service date are needed. The first stepis to enter the provider and service date.The next step is to enter member information. Enter the member’s DOB and either the member’ssubscriber ID or name. A complete last name must be entered but a partial first name is allowed. Theuser has the option of checking member eligibility at this point by selecting the ‘Verify Eligibility’ link.The results of the eligibility check will be displayed below the member information.Once identifying information is entered, the user selects the ‘Add To List Line’ button. The memberinformation is v
MassHealth Dental Program 2 Serving the MassHealth Program* MassHealth Dental Provider Quick Reference Directory Effective: January 1, 2013 masshealth-dental.net Provider Services
