MassHealth Presentation - November 2017 - Massachusetts League of ...
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MassHealth Presentation November 2017
Agenda
• Introductions / Overview
• Benefit Changes, July 1, 2017
• Orthodontic Billing Changes, November 1, 2017
• Children’s Medical Security Plan, July 1, 2017
• Benefit Changes, January 1, 2018
• Other Important Information
• MassHealth Outreach Programs
• Questions?
2
DentaQuest Team
Tracy Chase Gilman, Regional Director
Phone: 617-886-1310
E-mail: Tracy.Chase@Dentaquest.com
Marianne Leahy, Vice President, Network Management
Phone: 617-886-1206
E-mail: Marianne.Leahy@greatdentalplans.com
Keishia Lopez-Christian: Provider Relations Representative (Boston and Southern MA)
Phone: 617-886-1727
E-mail: Keishia.Lopez@DentaQuest.com
Daniel Archambault: Provider Relations Representative (Western MA)
Phone: 617-886-1736
E-mail: Daniel.Archambault@DentaQuest.com
Flor Piedrasanta: MassHealth Outreach Coordinator
E-mail: Flor.Piedrasanta@DentaQuest.com
3
Feedback
4 4
Public Health Dental Hygienists, New Codes
New Code: Description:
D0190 Oral Screening (New Code)
Screening of a patient: A screening, including state or federally mandated
CDT Definition screenings, to determine an individual’s need to be seen by a dentist for diagnosis.
Two (2) per calendar year per member, per provider. No prior authorization
Limitation required.
Adult- $20
Fees Under 21- $29
New Code: Description:
D0191 Limit Clinical Assessment (New Code)
Assessment of a patient: A limited clinical inspection that is performed to identify
CDT Definition possible signs of oral or systemic disease, malformation, or injury, and the potential
need for referral for diagnosis and treatment.
One (1) per calendar year per member, per provider. No prior authorization
Limitation Change required.
Adult- $20
Fees Under 21- $29
5
Dental Regulation: Diagnostic Services
• Oral Screening. The MassHealth agency pays for an oral screening twice
per calendar year per member per provider. An oral screening may only be
billed by Public Health Dental Hygienists. An oral screening includes state
or federally mandated screenings to determine a member’s need to be
seen by a dentist for further diagnosis.
• Limited Clinical Assessment. The MassHealth agency pays for a limited
clinical inspection once per calendar year per member per provider. A
limited clinical assessment may only be billed by Public Health Dental
Hygienists. A limited clinical assessment includes identification of possible
signs of oral or systemic disease, malformation, injury, and/or the
potential need for a referral for diagnosis and treatment by a dentist.
6
Dental Regulation: Provider Eligibility
420.404: Provider Eligibility: Participating Providers
• (A) A dentist or public health dental hygienist who is a member of a group practice
can direct payment to the group practice under the provisions of the MassHealth
regulations governing billing intermediaries in 130 CMR 450.000: Administrative
and Billing Regulations.
The dentist or public health dental hygienist providing the services must be enrolled as
an individual provider, and must be identified on claims for his or her services.
• (B) A dental school may claim payment for services provided in its dental clinic.
• (C) A dental clinic may claim payment for services provided in its dental clinic.
• (D) A community health center, hospital-licensed health center, or hospital
outpatient department may claim payment for services provided in its dental
clinic.
7
Dental Regulation: Provider Types
420.405: Provider Eligibility In-state and Out-of-state
• (2) Community Health Center. A licensed community health center with a dental clinic is
eligible to participate in MassHealth as a provider of dental services.
• (5) Dental Clinic. A dental clinic must be licensed by the Massachusetts Department of Public
Health (DPH) to be eligible to participate in MassHealth as a dental provider. A DPH license is
not required for a state owned and operated dental clinic. A dental clinic that limits its
services to education and diagnostic screening is not eligible to participate in MassHealth as a
dental provider.
• (9) Public Health Dental Hygienist. A dental hygienist engaged in private practice is eligible to
participate in MassHealth as a dental provider and claim payment for certain services without
the direct supervision of a dentist if he or she is licensed to practice as a registered dental
hygienist by BORID and also meets the Board’s requirements to practice in a public health
setting pursuant to 234 CMR 2.00: General Rules and Requirements et seq. Private practices
may include, but are not limited to, solo, partnership, or group practices.
8
Silver Diamine Fluoride
Code Definition Covered?
D1354 Interim carries arresting Non-covered
medicament application, per
tooth
Conservative treatment of an
active, non-symptomatic
carious lesion by topical
application of caries arresting
or inhibiting medicament and
without mechanical removal
of sound tooth structure.
9Denture Radiograph Requirement
Removable Prosthodontics (Full and Partial Dentures)
• Some procedures require retrospective review documentation. Please refer to Exhibits A-D covered
services tables for specific information needed by code.
Documentation needed for procedure:
• If the member still has natural teeth, appropriate pre-operative radiographs showing clearly the
adjacent and opposing teeth: bitewings, periapicals or panoramic radiograph are required. If the
member has no remaining teeth, radiographs are not required. Appropriate pre-operative radiographs
are required for patients who just became edentulous and all non-edentulous patients clearly showing
the adjacent and opposing teeth or if edentulous, the edentulous jaw : bitewings, periapicals or a
panoramic radiograph are required.
Criteria for Removable Prosthodontics (Full and Partial Dentures)
• Prosthetic services are intended to restore oral form and function caused by premature loss of
permanent teeth that would result in significant occlusal dysfunction.
• A denture is determined to be an initial placement if the patient has never before worn a prosthesis or
had a prosthesis prescribed by any provider at any time.
• Dentists are required to take diagnostic quality pre-operative radiographs for complete denture services.
10Periodontal Code Changes, Effective July 1, 2017
Codes: Description:
D4341-Periodontal scaling and root planning - four (4) or more teeth per quadrant.
D4341, D4342 D4342-Periodontal scaling and root planning – one (1) to three (3) teeth per quadrant
Limitation changed from thirty six (36) months to three (3) calendar years. (Beginning of the 3rd
calendar year)
Not payable in conjunction with D1110 and D1120 or D4210 and D4211 on the same date of
service.
Limitation Change Office:
One (1) of D4341 or D4342 per three (3) calendar years per patient, per quadrant.
Two (2) of D4341 or D4342 per one (1) day per provider or location in office.
Hospital:
Four (4) of D4341, D4342 per one (1) day per provider or location in hospital.
11Benefit / Language Changes
12Benefit Changes, Effective July 1, 2017
New Code: Description:
D0180 Comprehensive Periodontal Evaluation (New Code)
MassHealth Under 21
MassHealth Adult
MassHealth DDS
Who is covered?
HSN Only Under 21
HSN Only Adult
One (1) per calendar year per provider or location. No prior authorization.
Not covered with D9110 Palliative (emergency) treatment of dental pain – minor
Limitation procedure or D0140 limited oral evaluation – problem focused, by same provider
or provider group on same date of service.
Periodontal charting to be maintained in patient’s chart.
Adult: $37
Fees
Under 21: $58
13Benefit Changes, Effective July 1, 2017
Code: Description:
D0330 Panoramic Radiographs
Payment will not be allowed for D0330 if it billed on the same date of service
Limitation Change with codes related to orthodontic, crowns, endodontic codes, periodontic codes
or restorations / interproximal caries.
Codes: Description:
D2140-D2394 Restorations (Fillings) (Calendar year + Reimbursement Cap)
Limitation change from twelve (12) months to a calendar year.
One (1) per calendar year per provider per location per tooth.
Limitation Change MassHealth will not pay for restorations placed on two (2) or more surfaces within
twelve (12) months on the same tooth as separate restorations. Claim submitted as
separate restorations will be paid at the appropriate multi surface restoration
rates.
14Benefit Changes, Effective July 1, 2017
Updated November 2017- Coming
Code:
Description:
D0270, D0272,
Bitewing Radiographs
D0273, D0274
Two of (D0270, D0272, D0273, D0274)
per 1 Calendar year(s) Per Provider OR
Location. One of (D0270, D0272, D0273,
D0274) per 1 Day(s) Per patient. Only one of
(D0270, D0272, D0273, D0274) can be billed
on the same date of service. Any
combination of radiographs that exceeds
the maximum allowable payment for a
FMX will be reimbursed at the D0210 rate.
Documentation of variation from ADA
clinical guidelines to be kept in patient
Limitation Change record.
Any combination of radiographs that exceeds the maximum allowable payment for
a FMX will be reimbursed at the D0210 rate. Documentation of variation from ADA
clinical guidelines to be kept in patient record.
For Example:
• Deny the D0272 (double) and D0272 (double) from being billed together on the
same date.
• Deny the D0270 (single) and D0273 (triple) from being billed together on the same
date.
15Orthodontic Benefit Changes, Effective November 1, 2017
Codes: Description:
D8670 Periodic Orthodontic Treatment Visit
Codes: Description:
Action D8670 Periodic Orthodontic Treatment Visit
• Change billing cycle from monthly to quarterly
(every 90 days)
• Each quarterly billing period starts on the date
the member receives the first adjustment
• The first date that a quarterly payment for an
Action adjustment can be paid is for a date of service
in the month after the last date of service
claim. For example, if an adjustment service
was paid for the date of service of October 15,
2017 the earliest date a quarterly adjustment
payment could be paid would be November 1,
2017
• One of D8670 per 90 day(s) per patient. The
first adjustment (D8670) may not be billed in
the same calendar month as banding (D8070,
D8080)
Limitation Limitation • Only payable to a dental provider with a
specialty of Orthodontics
• Please review billing instructions in Section 16
of the Office Reference Manual
$268/Child-EPSDT (under 21)
Fee: Fee: $200/Adult (21 and over)
16Children’s Medical Security Plan (CMSP)
• DentaQuest became the TPA for the Children’s Medical Security Plan Effective July 1, 2017.
• The Children's Medical Security Plan (CMSP) is a program that provides certain uninsured
children and adolescents with primary and preventive medical and dental coverage.
• Populations Served:
o CMSP is for children under the age of 19 who are Massachusetts residents at any income
level, who do not qualify for MassHealth (except MassHealth Limited), and who are
uninsured.
• Some examples of services not covered by CMSP under MassHealth include:
o Cosmetic Services
o Orthodontic Services
• Please note:
o The service history for MassHealth and the Health Safety Net will be taken into
consideration prior to payment for any covered service.
17Children’s Medical Security Plan (CMSP)
MassHealth- State Fiscal Year Annual Maximum:
• CMSP-covered services include dental services, up to the $750 maximum per state fiscal year
(SFY), including preventive dental care under the MassHealth plan.
• CMSP benefits are calculated on a state fiscal-year basis. The state fiscal year starts on July
1st and continues through June 30th.
• Members who have only CMSP coverage or choose to see a provider who is not a Health
Safety Net (HSN) participating provider may have a patient responsibility after the processing
of claims once the $750 state fiscal year maximum has been reached.
• If a member has CMSP and HSN coverage and they see a Health Safety Net participating
provider, the balance remaining or any other covered services provided after reaching the
SFY maximum will be paid under the Health Safety Net with no patient responsibility.
18Children’s Medical Security Plan (CMSP)
SPECIAL NOTE:
• As of July 1, 2017 the CMSP remittance advice may not always correctly calculate the
member financial responsibility for members who have reached the $750 annual allowable
maximum per state fiscal year.
• The issue is actively being worked and MassHealth will communicate to the providers when
the corrections to the logic to calculate member responsibility have been made.
• Until a fix has been implemented providers can determine the member responsibility in the
following manner:
o If the members reaches the $750 annual allowable maximum within a state fiscal year
the service line will reference a processing policy 2550- Remaining Patient Liability
Present (Detail). This information will alert the provider that there is member payment
responsibility associated with the service.
o If MassHealth has paid a partial amount before the member reaches their maximum the
provider is held to the MassHealth allowable amount. In this instance the member
responsibility is the difference between the amount paid by MassHealth and the
MassHealth allowable amount (fee).
o If nothing was paid by MassHealth the service is considered non-covered. The provider
may charge the member the MassHealth allowable amount (fee).
19Accumulator- CMSP MassHealth
This image cannot currently be displayed.
20CMSP MassHealth
Accumulator Calculator
21Remove Codes, Effective January 1, 2018
Code Description Limitation Action
D5510 Repair broken complete denture Not allowed within 6 months of Remove Code
base initial
placement. All adjustments,
repairs to
acrylic or framework, as well as
replacement and/or addition of
any teeth
to the prosthesis are considered
part of
the prosthetic code fee and are
not
billable.
D5610 Repair resin denture Not allowed within 6 months of Remove Code
initial
placement. All adjustments,
repairs to
acrylic or framework, as well as
replacement and/or addition of
any teeth
to the prosthesis are considered
part of
the prosthetic code fee and are
not
billable.
D5620 Repair cast framework Not allowed within 6 months of Remove Code
initial
placement. All adjustments,
repairs to
acrylic or framework, as well as
replacement and/or addition of
any teeth
to the prosthesis are considered
part of
the prosthetic code fee and are
not billable.
22New Codes, Effective January 1, 2018
Code Description Limitation Fees Action
D5511 Repair broken complete Not allowed within 6 Under 21 $109 Add
denture base, months of initial Adult $79
mandibular placement. All
adjustments, repairs to
acrylic or framework, as
well as
replacement and/or
addition of any teeth
to the prosthesis are
considered part of
the prosthetic code fee
and are not
billable.
D5512 Repair broken complete Not allowed within 6 Under 21 $109 Add
denture base, maxillary months of initial Adult $79
placement. All
adjustments, repairs to
acrylic or framework, as
well as
replacement and/or
addition of any teeth
to the prosthesis are
considered part of
the prosthetic code fee
and are not
billable.
23New Codes, Effective January 1, 2018
Code Description Limitation Fees Action
D5611 Repair resin partial Not allowed within 6 Under 21 $93 Add
denture base, months of initial Adult $72
mandibular placement. All
adjustments, repairs to
acrylic or framework, as
well as
replacement and/or
addition of any teeth
to the prosthesis are
considered part of
the prosthetic code fee
and are not
billable.
D5612 Repair resin partial Not allowed within 6 Under 21 $93 Add
denture base, maxillary months of initial Adult $72
placement. All
adjustments, repairs to
acrylic or framework, as
well as
replacement and/or
addition of any teeth
to the prosthesis are
considered part of
the prosthetic code fee
and are not
billable.
24New Codes, Effective January 1, 2018
Code Description Limitation Fee Action
D5621 Repair cast partial Not allowed within 6 Under 21 $121 Add
framework, months of initial Adult $97
mandibular placement. All
adjustments, repairs to
acrylic or framework,
as well as
replacement and/or
addition of any teeth
to the prosthesis are
considered part of
the prosthetic code fee
and are not
billable.
D5622 Repair cast partial Not allowed within 6 Under 21 $121 Add
framework, maxillary months of initial Adult $97
placement. All
adjustments, repairs to
acrylic or framework,
as well as
replacement and/or
addition of any teeth
to the prosthesis are
considered part of
the prosthetic code fee
and are not
billable.
25New Codes, Effective January 1, 2018
Code Description Fee Action
D9222 Deep Sedation / General Under 21 $109 Add
Anesthesia- First 15 minutes Adult $73
D9239 Intravenous Moderate Under 21 $101 Add
(Conscious) Sedation / Adult $84
Anesthesia- First 15 minutes
26Codes to be Edited, January 1, 2018
Code Description Limitation Fees Action
D9223 Deep sedation / general Under 21 $109 Edit
anesthesia- each Adult $73
additional 15 minute
increment
D9243 intravenous moderate Five of (D9243) per 1 Under 21 $101 Edit
(conscious) Day(s) Per patient. Adult $84
sedation/analgesia –
each additional 15
minute increment
27Other Important Information
28Third Party Liability Claims (TPL)
• Check member eligibility on the MassHealth Web Portal
• If member is eligible, click on member number to check if member has other
primary insurance
• If a member has a primary insurance, you must submit the claim to the primary
insurance(s) first
• All TPL claims must have an Explanation of Benefits (EOB) from the primary
insurance, or a letter documenting the member’s termination from the primary
insurance, attached to the MassHealth claim, to prevent a claim DENIAL
• Primary EOB’S must be submitted with the primary insurance name and logo on
the EOB. Partial EOB’s will not be accepted
• To download full EOB, your office must have the correct profile set on the
primary payer’s web site
• If the member’s primary coverage terminates, the member must call MassHealth
Customer Services (1-800-841-2900) to update their information
29MassHealth Web Portal
Resources- “Related Documents”
• Office Reference Manual (ORM)
• Fee Schedule
• Massachusetts W-9
• Electronic Funds Transfer (EFT) Form for Direct Deposit
• Presentations, Newsletters, etc.
• MassHealth Dental Provider Web Portal Presentation
30Bell Notifications
*The Bell on Top Tool Bar Will Have a Red Dot When a
New Notice Has Been Posted
31Helpful Internet Links & Resources
• Provider Web Portal – Check eligibility, submit authorizations & claims
https://masshealth-dental.net
• Vendor Web – Use this to check on payment status
https://massfinance.state.ma.us/VendorWeb/vendor.asp
• NPPES – Use to obtain, verify, and update NPI information
https://nppes.cms.hhs.gov/NPPES/Welcome.do
• Regulations Updates – Sign-up to get notified of any changes in the regulations
mailto: join-masshealth-provider-pubs@listserv.state.ma.us
• IVR/Call Center - (800)-207-5019 available 24 hours a day / 7 days per week
32MassHealth Outreach Programs
33Fluoride Varnish in a Medical Setting
• Integrate medical and dental care through the promotion of the fluoride
varnish program.
• Provide training and guidance regarding the importance of oral health,
applying fluoride varnish, the importance of age one visits and referral to a
dental home.
• Provide support for the implementation of fluoride varnish application in
the medical setting to include training, billing support and tools for referral.
31Fluoride Varnish in a Medical Setting, continued
Promoting Oral Health and Fluoride Varnish in Medical Offices
32Collateral Material
We’ve expanded this program to include more tools and support for the medical offices
as well as updated materials.
• Materials Available:
o Baby Teeth Brochures
o Educational Posters
o New Survey
33DentaQuest - Additional Resources
Megan Mackin: Outreach Coordinator
Phone: 617-886-1728
E-mail: Megan.Mackin@DentaQuest.com
Sean Moran: Provider Intervention Specialist
Phone: 617-886-1463
E-mail: Sean.Moran@DentaQuest.com
Giovani Romero: Member Intervention Specialist
Phone: 617-886-1219
E-mail: Giovani.Romero@DentaQuest.com
37Questions
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