reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 420.000 - Dental Services › Section 420.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
MassHealth Members
.
			 130 CMR 450.105:
Coverage Types
specifically states for each MassHealth
			 coverage type, which members are eligible to receive dental services. The
			 MassHealth agency pays for dental services described in
			 130 CMR
			 420.000, provided to eligible MassHealth
			 members.
(B)
Recipients
			 of Emergency Aid to the Elderly, Disabled and Children Program
.
			 130 CMR
			 450.106:
Emergency Aid to the
			 Elderly
, Disabled and Children Program provides information on
			 services available to recipients of the Emergency Aid to the Elderly, Disabled
			 and Children (EAEDC) program.
(C)
Member Eligibility and Coverage Type
.
			 130 CMR
			 450.107:
Eligible Members
and the MassHealth Card provides information on verifying member eligibility
			 and coverage type.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 420.000 - Dental Services › Section 420.404 - Provider Eligibility: Participating Providers

Current through Register 1525, July 5, 2024
The MassHealth agency pays for services described in
				130 CMR
				420.000 only to providers of dental services who are
				participating in MassHealth on the date of service. The participating provider
				is responsible for the quality of all services for which payment is claimed,
				the accuracy of such claims, and compliance with all regulations applicable to
				dental services under MassHealth. To claim payment, the participating provider
				must be the individual who actually performed the service, except as described
				in 130 CMR 420.404(A) through (D).
(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.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 420.000 - Dental Services › Section 420.406 - Caseload Capacity

Current through Register 1525, July 5, 2024
(A) A provider must
			 immediately notify the MassHealth agency when its individual, group, or
			 facility practice has reached the maximum number of MassHealth members it can
			 accept and also when its practice is accepting new MassHealth
			 members.
(B) Group practices,
			 community health centers, hospital-licensed health centers, and acute hospital
			 outpatient departments that choose to establish a caseload capacity must
			 establish a single caseload capacity for the entire group or
			 facility.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 420.000 - Dental Services › Section 420.407 - Maximum Allowable Fees

Current through Register 1525, July 5, 2024
The MassHealth agency pays for dental services with rates set
				by the Executive Office of Health and Human Services (EOHHS) at
				101
				CMR 314.00: Dental Services, subject to the
				conditions, exclusions, and limitations set forth in
				130 CMR
				420.000 and
				130 CMR 450.000:
Administrative and Billing Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 420.000 - Dental Services › Section 420.408 - Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for all medically necessary dental
				services for EPSDT-eligible members in accordance with
				130
				CMR 450.140:
Early and Periodic
				Screening, Diagnostic and Treatment (EPSDT) Services: Introduction
,
				without regard to service limitations described in
				130 CMR
				420.000, and with prior
				authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 420.000 - Dental Services › Section 420.409 - Non-covered Circumstances

Current through Register 1525, July 5, 2024
(A)
Conditions
. The MassHealth agency does not pay for
			 dental services under any of the following conditions:
(1) services provided in a state institution
			 by a state-employed dentist, dental consultant, or public health dental
			 hygienist;
(2) services provided by
			 a provider whose salary includes compensation for professional
			 services;
(3) if, under comparable
			 circumstances, the provider does not customarily bill individuals who do not
			 have health insurance; and
(4) if
			 the member is not an eligible MassHealth member on the date of service. The
			 provider must verify the member's eligibility for MassHealth on the date of
			 service even if the provider has obtained prior authorization for the
			 service.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 420.000 - Dental Services › Section 420.410 - Prior Authorization

Current through Register 1525, July 5, 2024
(A)
Introduction
.
(1) The
			 MassHealth agency pays only for medically necessary services to eligible
			 MassHealth members and may require that medical necessity be established
			 through the prior authorization process. In some instances, prior authorization
			 is required for members 21 years of age or older when it is not required for
			 members younger than 21 years old.
(2) Services requiring prior authorization
			 are identified in Subchapter 6 of the
Dental Manual
, and may
			 also be identified in billing instructions, program regulations, associated
			 lists of service codes and service descriptions, provider bulletins, and other
			 written issuances. The MassHealth agency only reviews requests for prior
			 authorization where prior authorization is required or permitted
			 (
see
130 CMR 420.410(B)) .
(3) The provider must not start a service
			 that requires prior authorization until the provider has requested and received
			 written prior authorization from the MassHealth agency. The MassHealth agency
			 may grant prior authorization after a procedure has begun if, in the judgment
			 of the MassHealth agency
(a) the treatment was
			 medically necessary;
(b) the
			 provider discovers the need for additional services while the member is in the
			 office and undergoing a procedure; and
(c) it would not be clinically appropriate to
			 delay the provision of the service.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 420.000 - Dental Services › Section 420.411 - Pretreatment Review

Current through Register 1525, July 5, 2024
When the MassHealth agency identifies an unusual pattern of
				practice of a given provider, the MassHealth agency, at its discretion and
				pursuant to written notice, may require the provider to submit any proposed
				treatments identified by the MassHealth agency, including those not otherwise
				subject to prior authorization, for the MassHealth agency's review and approval
				before treatment.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 420.000 - Dental Services › Section 420.412 - Individual Consideration

Current through Register 1525, July 5, 2024
(A) Certain
			 services, including unspecified procedures, are designated "IC" (individual
			 consideration) in Subchapter 6 of the
Dental Manual
and in the
			 EOHHS pricing regulation for dental services,
			 101
			 CMR 314.00:
Dental Services
. This
			 means that a fee could not be established for these services. The MassHealth
			 agency determines appropriate payment for individual-consideration services
			 from the provider's detailed report of services provided (see Subchapter 6 of
			 the
Dental Manual
for report requirements). The MassHealth
			 agency does not pay claims for "IC" services without a complete report (see
			 130 CMR
			 420.415) . If the documentation is illegible
			 or incomplete, the MassHealth agency denies the claim.
(B) The MassHealth agency determines the
			 appropriate payment for an individual-consideration service in accordance with
			 the following standards and criteria:
(1) the
			 amount of time required to perform the service;
(2) the degree of skill required to perform
			 the service;
(3) the severity and
			 complexity of the member's disease, disorder, or disability; and
(4) any extenuating circumstances or
			 complications.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 420.000 - Dental Services › Section 420.413 - Separate Procedures

Current through Register 1525, July 5, 2024
Certain procedures are designated "SP" (separate procedure) in
				the service descriptions in Subchapter 6 of the
Dental Manual
.
				A separate procedure is one that is commonly performed as an integral part of a
				total service and therefore does not warrant a separate payment, but that
				commands a separate payment when performed as a separate procedure not
				immediately related to other services. For example,
(A) the MassHealth agency does not pay for a
			 frenulectomy when it is performed as part of a vestibuloplasty, and full-study
			 models are not payable separately when performed as part of orthodontic
			 treatment or diagnosis. Nevertheless, the MassHealth agency does pay for
			 frenulectomy as a separate procedure when medically necessary; and
(B) the MassHealth agency does not pay for
			 restorations placed on two or more surfaces within 12 months on the same tooth
			 as separate restorations at the one-surface rate. Claims submitted as separate
			 restorations will be paid at the appropriate multi-surface restoration rates
			 set by EOHHS at
			 101
			 CMR 314.00:
Dental Services
, subject
			 to the conditions, exclusions, and limitations set forth in
			 130 CMR
			 420.000 and
			 130 CMR 450.000:
Administrative and Billing Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 420.000 - Dental Services › Section 420.414 - Recordkeeping Requirements

Current through Register 1525, July 5, 2024
(A)
Record Retention
. Federal and state regulations
			 require that all MassHealth providers maintain complete written records of
			 patients who are members. All original records, including original radiographs
			 (physical or electronic), must be kept for a minimum of four years after the
			 date of service. Records for members who are residents of long-term-care
			 facilities must be retained by the dentist as part of the member's dental
			 record and by the nursing facility as part of the member's record at the
			 facility.
(B)
Dental
			 Record
. Payment by the MassHealth agency for
Dental
			 Services
listed in
			 130 CMR
			 420.000 includes payment for preparation of the
			 member's dental record, including electronic dental records. Services for which
			 payment is claimed must be substantiated by clear evidence of the nature,
			 extent, and necessity of care provided to the member. For all claims under
			 review, the member's medical and dental records determine the appropriateness
			 of services provided to members. The written dental record corresponding to the
			 services claimed must include, but is not limited to:
(1) the member's name, date of birth, and
			 sex;
(2) the member's
			 identification number;
(3) the date
			 of each service;
(4) the name and
			 title of the individual servicing provider furnishing each service, if the
			 dental provider claiming payment is not a solo practitioner;
(5) pertinent findings on examination and in
			 medical history;
(6) a description
			 of any medications administered or prescribed and the dosage given or
			 prescribed;
(7) a description of
			 any anesthetic agent administered, the dosage given, and the anesthesia
			 flowsheet;
(8) a complete
			 identification of treatment including, when applicable, the arch, quadrant,
			 tooth number, and tooth surface;
(9) dated digital or mounted radiographs, if
			 applicable; and
(10) copies of all
			 approved prior authorization requests or the prior authorization
			 number.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 420.000 - Dental Services › Section 420.415 - Report Required with Certain Claims

Current through Register 1525, July 5, 2024
(A)
			 The provider must submit with the claim for payment, a written description of
			 the service provided in accordance with the requirements described in
			 Subchapter 6 of the
Dental Manual
when
(1) the service description in Subchapter 6
			 stipulates "by report"; or
(2) the
			 service is designated in Subchapter 6 as "IC".
See
130 CMR
			 420.412.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 420.000 - Dental Services › Section 420.421 - Covered and Non-covered Services: Introduction

Current through Register 1525, July 5, 2024
(A)
Medically Necessary
			 Services
. The MassHealth agency pays for the following
Dental Services
when medically necessary:
(1) the services with codes listed in
			 Subchapter 6 of the
Dental Manual
, in accordance with the
			 service descriptions and limitations described in
			 130 CMR
			 420.422 through
			 420.456;
			 and
(2) all services for
			 EPSDT-eligible members, in accordance with
			 130
			 CMR 450.140 through
			 450.149,
			 without regard for the service limitations described in
			 130 CMR
			 420.422 through
			 420.456,
			 or the listing of a code in Subchapter 6. All such services are available to
			 EPSDT-eligible members, with prior authorization, even if the limitation
			 specifically applies to other members younger than 21 years
			 old.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 420.000 - Dental Services › Section 420.423 - Service Descriptions and Limitations: Radiographs

Current through Register 1525, July 5, 2024
(A)
Introduction and
			 Definitions
.
(1) The MassHealth
			 agency pays for radiographs/diagnostic imaging taken as an integral part of
			 diagnosis and treatment planning.
(a)
Assessing Extent of Required Radiographs
. Providers
			 should conduct a clinical examination; consider the member's oral and medical
			 histories, as well as the member's vulnerability to environmental factors that
			 may affect the oral health before conducting a radiographic examination to
			 determine the type of imaging, frequency, and number of images. Radiographs
			 should be taken only when there is an expectation that the diagnostic yield
			 will affect patient care. The intent is to confine radiation exposure of
			 members to the minimum necessary to achieve satisfactory diagnosis.
(b) The provider must document efforts to
			 obtain any previous radiographs/diagnostic imaging before prescribing
			 more.
(c) When radiographs and
			 diagnostic imaging submitted to the MassHealth agency as part of the prior
			 authorization process or upon other request are not of good diagnostic quality,
			 the provider may not claim payment for any retake of radiographs/diagnostic
			 imaging requested by the MassHealth agency.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 420.000 - Dental Services › Section 420.424 - Service Descriptions and Limitations: Preventive Services

Current through Register 1525, July 5, 2024
(A)
Prophylaxis
. The
			 MassHealth agency pays for prophylaxis twice per member per calendar year. The
			 prophylaxis must include the removal of plaque, calculus, and stains from the
			 tooth structures. MassHealth requires the provider to perform as part of this
			 service, oral hygiene instruction including, but not limited to, proper tooth
			 brushing and flossing instructions, and use of oral hygiene aids. The
			 MassHealth agency does not pay a separate fee for oral hygiene
			 instruction.
(B)
Fluoride
.
(1)
Topical Fluoride Treatment
.
(a)
Members Younger than 21 Years
			 Old
. The MassHealth agency pays for topical fluoride treatment
			 every 90 days per member, per provider or location. Topical fluoride treatment
			 consists of continuous topical application of an approved fluoride agent such
			 as gels, foams, and varnishes, for a period shown to be effective for the
			 agent. The MassHealth agency pays for treatment that incorporates fluoride with
			 the polishing compound as part of the prophylaxis procedure. The MassHealth
			 agency does not pay for treatment that incorporates fluoride with the polishing
			 compound as a separate procedure.
(b)
Members 21 Years of Age or
			 Older
. The MassHealth agency pays for topical fluoride only for
			 members who have medical or dental conditions that significantly interrupt the
			 flow of saliva. Providers must submit a prior authorization request for this
			 treatment for members 21 years of age or older.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 420.000 - Dental Services › Section 420.425 - Service Descriptions and Limitations: Restorative Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for restorative services in
				accordance with the service descriptions and limitations in 130 CMR 420.425(A)
				through (E). The MassHealth agency considers all of the following to be
				components of a completed restoration (local anesthesia tooth preparation, acid
				etching, all adhesives applications, resin bonding agents, amalgam bonding
				agents, liners, bases, amalgams, resin-based composites, glass ionomers, curing
				and polishing) and includes them in the payment for this service. The
				MassHealth agency does not pay for composite or amalgam restorations replaced
				within one year of the date of completion of the original restoration when
				replaced by the same provider or dental group. The initial payment includes all
				restorations replaced due to defects or failure less than one year from the
				original placement.
(A)
Amalgam Restorations
. The MassHealth agency does not
			 pay for restorations on primary teeth when early exfoliation (more than 
			 2/3 of the root
			 structure resorbed) is expected.
(B)
Resin-based Composite
			 Restorations
.
(1) The MassHealth
			 agency pays for:
(a) all resin-based
			 composite restorations for all surfaces of anterior and posterior teeth;
			 and
(b) full-coverage composite
			 crowns only for members younger than 21 years old, only for anterior primary
			 teeth.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 420.000 - Dental Services › Section 420.426 - Service Descriptions and Limitations: Endodontic Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for endodontic services including
				all radiographs performed with the exception of panoramic radiographs, during
				the treatment visit. The MassHealth agency pays for endodontic services for all
				MassHealth members in accordance with the service descriptions and limitations
				described in 130 CMR 420.426.
(A)
Pulpotomy
.
(1) The
			 MassHealth agency pays for a therapeutic pulpotomy for members younger than 21
			 years old only.
(2) Therapeutic
			 pulpotomy is the surgical removal of a portion of the pulp with the aim of
			 maintaining the vitality of the remaining portion by means of an adequate
			 dressing. This procedure is performed on primary or permanent teeth. It is
			 limited to instances when the prognosis is favorable, and must not be performed
			 on primary teeth that are ready to exfoliate or permanent teeth with advanced
			 periodontal disease or to be used for apexogenesis.
(3) The MassHealth agency does not pay for
			 pulpotomy on deciduous teeth that are ready to exfoliate.
(4) The MassHealth agency does not pay for
			 pulpotomy as the first stage of root canal therapy.
(5) The MassHealth agency does not pay for a
			 pulpotomy performed on the same date of service as root canal therapy. (See
			 130 CMR
			 420.456(C)  regarding
			 palliative treatment.)
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 420.000 - Dental Services › Section 420.428 - Service Descriptions and Limitations: Prosthodontic Services (Removable)

Current through Register 1525, July 5, 2024
(A)
General Conditions
. The MassHealth agency pays for
			 dentures services once per seven calendar years per member, subject to the age
			 limitations specified in 130 CMR 420.428(B). MassHealth payment includes all
			 services associated with the fabrication and delivery process, including all
			 adjustments necessary in the six months following insertion. The member is
			 responsible for all denture care and maintenance following insertion. The
			 MassHealth agency does not pay for complete dentures when the member's medical
			 record indicates material limitations to the member's ability to cooperate
			 during the fabrication of the denture or to accept or function with the
			 denture, or indications that the member does not intend to utilize the
			 denture.
(B)
Prosthodontic Services
. The MassHealth agency pays for
			 complete dentures for all members. The MassHealth agency pays for immediate
			 dentures, including relines and post insertion procedures and placement of
			 identification, for members younger than 21 years old.
(C)
Denture
			 Procedures
.
(1) All denture
			 services require appropriate diagnostic quality radiographs to be taken and
			 stored in the member's chart.
(2)
			 As part of the denture fabrication process, the member must approve the teeth
			 and setup in wax and try on the denture setup at a try-in visit before the
			 dentures are processed.
(3) The
			 member's identification must be on each denture.
(4) All dentures must be initially inserted
			 and subsequently examined and can be adjusted up to six months after the date
			 of insertion by the dentist at reasonable intervals consistent with the
			 community standards.
(5) If a
			 member does not return for the insertion of the completed processed denture,
			 the provider is required to submit to the MassHealth agency written evidence on
			 their office letterhead of at least three attempts to contact the member over a
			 period of one month via certified mail return receipt requested. Upon providing
			 documentation, the provider may be reimbursed a percentage of the denture fee
			 to assist in covering costs.
See
130 CMR
			 450.231:
General Conditions of
			 Payment
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 420.000 - Dental Services › Section 420.429 - Service Descriptions and Limitations: Prosthodontic Services (Fixed)

Current through Register 1525, July 5, 2024
(A)
Fixed Partial
			 Dentures/Bridges
. The MassHealth agency pays for fixed partial
			 dentures/ bridge for anterior teeth only for members younger than 21 years old
			 with two or more missing permanent teeth. The member must not have active
			 periodontal disease and the prognosis for the life of the bridge and remaining
			 dentition must be excellent.
(B)
Fixed Partial Denture/Bridge Repair
. The MassHealth
			 agency pays for chairside fixed partial denture/bridge repair. A description of
			 the repair must be documented in the member's dental record.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 420.000 - Dental Services › Section 420.430 - Covered Service Descriptions and Limitations: Oral and Maxillofacial Surgery Services

Current through Register 1525, July 5, 2024
(A)
General Requirements
.
(1) The MassHealth agency pays for oral and
			 maxillofacial surgery services for all members, regardless of age, subject to
			 the service descriptions and limitations as described in 130 CMR 420.430.
			 Payment for oral and maxillofacial surgery includes payment for local
			 anesthesia, suture removal, irrigations, bony spicule removal, apical curettage
			 of associated cysts and granulomas, enucleation of associated follicles, and
			 routine preoperative and postoperative care.
(2) The MassHealth agency pays for routine
			 extractions provided in an office, hospital, or freestanding ambulatory surgery
			 center. Use of a hospital or freestanding ambulatory surgery center for
			 extractions is limited to those members whose health, because of a medical
			 condition, would be at risk if these procedures were performed in the
			 provider's office. Member apprehension alone is not sufficient justification
			 for use of a hospital or freestanding ambulatory surgery center. Lack of
			 facilities for the administration of general anesthesia when the procedure can
			 be routinely performed with local anesthesia does not justify the use of a
			 hospital or a freestanding ambulatory surgery center.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 420.000 - Dental Services › Section 420.431 - Service Descriptions and Limitations: Orthodontic Services

Current through Register 1525, July 5, 2024
(A)
General
			 Conditions
. The MassHealth agency pays for orthodontic treatment,
			 subject to prior authorization, service descriptions and limitations as
			 described in 130 CMR 420.431. The provider must seek prior authorization for
			 orthodontic treatment and begin initial placement and insertion of orthodontic
			 appliances and partial banding or full banding and brackets prior to the
			 member's 21st birthday.
(B)
Definitions
.
(1)
Pre-orthodontic Treatment
			 Examination
. Includes the periodic observation of the member's
			 dentition at intervals established by the orthodontist to determine when
			 orthodontic treatment should begin.
(2)
Interceptive Orthodontic
			 Treatment
. Includes treatment of the primary and transitional
			 dentition to prevent or minimize the development of a handicapping malocclusion
			 and therefore, minimize or preclude the need for comprehensive orthodontic
			 treatment.
(3)
Comprehensive Orthodontic Treatment
. Includes a
			 coordinated diagnosis and treatment leading to the improvement of a member's
			 craniofacial dysfunction and/or dentofacial deformity which may include
			 anatomical and/or functional relationship. Treatment may utilize fixed and/or
			 removable orthodontic appliances and may also include functional and/or
			 orthopedic appliances. Comprehensive orthodontics may incorporate treatment
			 phases, including adjunctive procedures to facilitate care focusing on specific
			 objectives at various stages of dentofacial development.
(4)
Orthodontic Treatment
			 Visits
. Periodic visits which may include, but are not limited to,
			 updating wiring, tightening ligatures or otherwise evaluating and updating care
			 while undergoing comprehensive orthodontic treatment.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 420.000 - Dental Services › Section 420.452 - Service Descriptions and Limitations: Anesthesia

Current through Register 1525, July 5, 2024
(A)
General
			 Requirements
. The MassHealth agency pays for general anesthesia
			 and intravenous moderate (conscious) sedation/analgesia subject to the service
			 descriptions and limitations described in 130 CMR 420.452 and in accordance
			 with the service description of Subchapter 6 in the
Dental
			 Manual
.
(1)
Deep
			 Sedation/General Anesthesia
. Deep sedation and general anesthesia,
			 when administered in a dental office, must be administered only by a provider
			 who possesses both an anesthesia-administration permit and an
			 anesthesia-facility permit issued by the Massachusetts Board of Registration in
			 Dentistry (BORID) and when a member is eligible for oral-surgery services. All
			 rules, regulations, and requirements set forth by the Massachusetts BORID and
			 by the Massachusetts Society of Oral and Maxillofacial Surgeons must be
			 followed without exception.
(2)
Intravenous Moderate Sedation/Analgesia
. The
			 MassHealth agency pays for intravenous moderate sedation/analgesia sedation
			 when administered in a dental office, and when a member is eligible for
			 oral-surgery services, administered by a provider who possesses both an
			 anesthesia-administration permit and an anesthesia-facility permit issued by
			 the Massachusetts BORID.
(3)
Inhalation of Nitrous Oxide/Oral Analgesia
.
(a) The MassHealth agency pays for the oral
			 administration of analgesia, as part of an operative procedure.
(b) The MassHealth agency pays for the
			 administration of inhalation analgesia (nitrous oxide
			 (N2O/O2)) as a separate
			 procedure.
(4)
Local Anesthesia
. The MassHealth agency pays for the
			 administration of local anesthesia as part of an operative procedure. The
			 MassHealth agency does not pay for local anesthesia as a separate procedure
			 (see
			 130 CMR
			 420.413) .
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 420.000 - Dental Services › Section 420.455 - Service Descriptions and Limitations: Maxillofacial Prosthetics

Current through Register 1525, July 5, 2024
(A) The MassHealth agency pays for
			 maxillofacial prosthetics by providers who have completed a CODA certificate
			 program in maxillofacial prosthetics (as described in
			 130 CMR
			 420.405(A)(8)) and only
			 where the maxillofacial prosthetic device will be constructed for the treatment
			 of a member with congenital, developmental, or acquired defects of the mandible
			 or maxilla and associated structures.
(B) The MassHealth agency pays for opposing
			 appliances only when they are necessary for the balance or retention of the
			 primary maxillofacial prosthetic device.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 420.000 - Dental Services › Section 420.456 - Service Descriptions and Limitations: Other Services

Current through Register 1525, July 5, 2024
(A) Hospital or Freestanding Ambulatory
			 Surgical Center: Admission of Members with Certain Disabilities or Age-related
			 Behavior for Restorative, Endodontic, or Exodontic Dentistry.
(1) The MassHealth agency pays for a member
			 who is severely and chronically mentally and physically impaired, under certain
			 circumstances, to undergo restorative, endodontic, or exodontic dental
			 procedures for which they are eligible in a hospital or freestanding ambulatory
			 surgery center. Use of these facilities may be indicated for a member who
(a) has a condition that is reasonably likely
			 to place the member at risk of medical complications that require medical
			 resources that are not available in an office setting; (b) is extraordinarily
			 uncooperative, fearful, or anxious;
(c) has dental needs, but local anesthesia is
			 ineffective due to acute infection, idiosyncratic anatomy, or allergy;
			 or
(d) has sustained orofacial or
			 dental trauma, or both, so extensive that treatment cannot be provided safely
			 and effectively in an office setting.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 421.000 - Family Planning Agency Services › Section 421.401 - Introduction

Current through Register 1525, July 5, 2024
All providers of family planning agency services participating
				in MassHealth must comply with the MassHealth regulations at
				130 CMR 421.000 and
				130 CMR 450.000:
Administrative and Billing Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 421.000 - Family Planning Agency Services › Section 421.402 - Definitions

Current through Register 1525, July 5, 2024
The following terms used in
				130 CMR 421.000 have the
				meanings given in 130 CMR 421.402 unless the context clearly requires a
				different meaning. The reimbursability of services defined in
				130 CMR 421.000 is not
				determined by these definitions, but by application of regulations elsewhere in
				130 CMR 421.000 and
				450.000:
Administrative and Billing Regulations
.
Annual Visit
- a yearly visit during
				which comprehensive services, including medical, laboratory, and counseling
				services are provided.
HIV Pre- and Post-test Counseling
				Visit
- a face-to-face meeting between the member and a counselor
				for the purpose of providing counseling before and after HIV testing. Such
				counseling includes information about the implications of positive and negative
				test results, risk-reduction techniques, partner notification, and referral to
				medical and support services, in accordance with established protocols of the
				Massachusetts Department of Public Health.
Initial Visit
- a member's first visit
				during which comprehensive services, including medical, laboratory, and
				counseling services are provided.
Institutionalized Individual
- an
				individual who is
(1) involuntarily confined or detained, under a civil or
				criminal statute in a correctional or rehabilitative facility, including a
				psychiatric hospital or other facility for the care and treatment of mental
				illness; or
(2) confined, under a voluntary commitment, in a psychiatric
				hospital or other facility for the care and treatment of mental illness.
Mentally Incompetent Individual
- an
				individual who has been declared mentally incompetent by a federal, state, or
				local court of competent jurisdiction for any purpose, unless the individual
				has been declared competent for purposes that include the ability to consent to
				sterilization.
Minimal Visit
- a brief visit during
				which a family planning agency provides counseling services only or brief
				medical and counseling services.
Routine Visit
- a return visit,
				follow-up visit, or other visit that is neither an annual nor an initial
				visit.
Sterilization
- any medical procedure,
				treatment, or operation for the purpose of rendering an individual permanently
				incapable of reproducing.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 421.000 - Family Planning Agency Services › Section 421.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
(1)
MassHealth
			 Members
. MassHealth covers family planning agency services only
			 when provided to eligible MassHealth members, subject to the restrictions and
			 limitations described in the MassHealth regulations.
			 130 CMR 450.105:
Coverage Types
specifically states, for each MassHealth
			 coverage type, which services are covered and which members are eligible to
			 receive those services.
(2)
Recipients of the Emergency Aid to the Elderly, Disabled and
			 Children Program
. For information on covered services for
			 recipients of the Emergency Aid to the Elderly, Disabled and Children Program,
see
130 CMR
			 450.106:
Emergency Aid to the
			 Elderly, Disabled and Children Program
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 421.000 - Family Planning Agency Services › Section 421.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
Payment for the services described in
				130 CMR 421.000 is made
				only to family planning agencies that are participating in MassHealth as of the
				date of service. The eligibility requirements for family planning agencies are
				as follows.
(A)
In
			 State
.
(1) A family planning
			 agency located in Massachusetts is eligible to participate in MassHealth only
			 if it is certified by the MassHealth agency as a family planning agency, in
			 accordance with the requirements specified in 130 CMR 421.404 through
			 421.427.
(2) The family planning agency must fulfill
			 one of the following licensing requirements.
(a) Family planning services must be provided
			 in a facility licensed as a clinic or hospital by the Massachusetts Department
			 of Public Health.
(b) Family
			 planning services must be provided under the supervision of a physician
			 licensed by the Massachusetts Board of Registration in Medicine.
(3) A family planning agency may
			 provide family planning services in one or more service delivery sites, which
			 must be located in freestanding clinics, community health centers, hospital
			 outpatient departments, or hospital-licensed health centers.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 421.000 - Family Planning Agency Services › Section 421.405 - Staffing

Current through Register 1525, July 5, 2024
(A)
Personnel
			 Policies.
(1) Current job
			 descriptions must be available for all positions of the staff.
(2) Written personnel policies must be
			 available to all personnel.
(3) An
			 evaluation and review of the job performance of all personnel must be conducted
			 annually.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 421.000 - Family Planning Agency Services › Section 421.411 - Certification

Current through Register 1525, July 5, 2024
The MassHealth agency certifies only a comprehensive family
				planning agency, defined as a public or private agency that demonstrates the
				capability of providing family planning medical services, family planning
				counseling services, follow-up health care, outreach, and community
				education.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 421.000 - Family Planning Agency Services › Section 421.412 - Medical and Laboratory Services

Current through Register 1525, July 5, 2024
(A) For an
			 initial or annual visit, a family planning agency must provide all of the
			 following medical and laboratory services:
(1) a complete medical history (including
			 family and interval);
(2) a
			 physical examination:
(a) for a member who is
			 female, this includes thyroid, breast, heart, abdominal, speculum, pelvic, and
			 rectal examinations, and measurements of height, weight, and blood
			 pressure;
(b) for a member who is
			 male, this includes thyroid, heart, genital, abdominal, and rectal
			 examinations, and measurements of height, weight, and blood pressure;
(3) a Pap smear (for a female
			 member) as indicated by current nationally recommended protocols, such as
			 American College of Obstetrics and Gynecology (ACOG), American Cancer Society
			 (ACS), or the US Preventive Services Task Force (USPSTF);
(4) any laboratory test indicated by the
			 member's history or examination (such a test may be provided directly or by
			 referral);
(5) a medically approved
			 method of contraception, if appropriate; and
(6) referrals for the screening, diagnosis,
			 prevention, or treatment of general as well as reproductive medical
			 conditions.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 421.000 - Family Planning Agency Services › Section 421.413 - Counseling

Current through Register 1525, July 5, 2024
A family planning agency must provide counseling to assist
				members in achieving their family planning goals . Such couns e ling may
				included is cussing general health, human an atomy, physiology, reproduction,
				and all available methods of contraception. Specific information about the
				safety of a method (potential side effects or complications), its
				effectiveness, its acceptability to member and partner, and its correct usage
				must be given. Surgical procedures must be discussed if the member prefers a
				permanent method of contraception. Follow-up counseling may include
				reinforcement of contraceptive instructions and reproductive information,
				discussion of member concerns or problems, and additional
				education.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 421.000 - Family Planning Agency Services › Section 421.414 - Follow-up and Referral

Current through Register 1525, July 5, 2024
(A)
Follow-up
. The family planning agency must have a
			 system of contacting members who are patients of that family planning agency to
			 remind them of their annual visits.
(B)
Referral
.
(1) A family planning agency must have
			 arrangements with medical, social-service, and other community-service agencies
			 to which appropriate referrals may be made for member problems identified
			 during a family planning visit. The family planning agency must make referrals
			 for necessary services if those services are not available on site. These
			 services include, but are not limited to, the following:
(a) treatment of medical problems beyond the
			 scope of the family planning agency;
(b) follow-up on positive results of tests
			 for sexually transmitted disease or on other laboratory tests;
(c) pregnancy-related services;
(d) genetic counseling;
(e) sterilization services or information;
			 and
(f) social case work beyond the
			 scope of the family planning agency.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 421.000 - Family Planning Agency Services › Section 421.415 - Community Education

Current through Register 1525, July 5, 2024
(A) A family
			 planning agency must provide community education. The objectives of a community
			 education program include, but are not limited to, the following:
(1) promoting community awareness and support
			 of family planning services;
(2)
			 providing information about family planning or reproduction to interested
			 groups or individuals;
(3)
			 integrating family planning education into educational institutions and
			 community organizations; and
(4)
			 being a resource for other professionals in family planning
			 education.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 421.000 - Family Planning Agency Services › Section 421.416 - Outreach

Current through Register 1525, July 5, 2024
(A) A family planning agency must perform
			 outreach activities. The objectives of an outreach program include, but are not
			 limited to, the following:
(1) to make known
			 to an entire community the availability of family planning services;
(2) to encourage use of the agency's services
			 by certain populations, such as adolescents and persons eligible for
			 MassHealth, that are not currently receiving services adequate to meet their
			 needs; and
(3) to build linkages
			 and referrals with local agencies and professionals.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 421.000 - Family Planning Agency Services › Section 421.417 - Noncovered Services

Current through Register 1525, July 5, 2024
The MassHealth agency does not pay for the treatment of male or
				female infertility, including, but not limited to, laboratory tests, drugs, and
				procedures associated with such treatment; however, MassHealth does pay for the
				diagnosis of male or female infertility.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 421.000 - Family Planning Agency Services › Section 421.418 - Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for all medically necessary family
				planning services for EPSDT-eligible members in accordance with
				130
				CMR 450.140:
Early and Periodic
				Screening, Diagnosis and Treatment (EPSDT) Services: Introduction
through 450.149:
EPSDT: Recordkeeping Requirements
, without
				regard to service limitations described in
				130 CMR 421.000, and with
				prior authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 421.000 - Family Planning Agency Services › Section 421.421 - Coordination of Services

Current through Register 1525, July 5, 2024
When a family planning agency is located in a community health
				center, a hospital, or another primary-care setting, the agency must
				demonstrate that family planning services are coordinated with and integrated
				into other services delivered on site. Such coordination includes at a
				minimum:
(A) either one central medical
			 record for each member in which all medical and health-care services are
			 recorded, or a mechanism for transferring relevant information to medical
			 records to ensure continuity of care;
(B) avoidance of duplication of medical
			 examinations and laboratory tests; and
(C) in-house referrals, as
			 appropriate.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 421.000 - Family Planning Agency Services › Section 421.422 - Emergency Backup

Current through Register 1525, July 5, 2024
A family planning agency must have provisions for 24-hour
				emergency backup. Each member must be given the emergency telephone number in
				writing at the time of initiation of services. The telephone number must also
				be displayed prominently in the family planning agency.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 421.000 - Family Planning Agency Services › Section 421.423 - Recordkeeping Requirements

Current through Register 1525, July 5, 2024
(A) Payment for any
			 service listed in
			 130 CMR 421.000 is
			 conditioned upon its full and complete documentation in the member's medical
			 record. A family planning agency must maintain a record of all medical and
			 contraceptive services provided to a member for at least six years following
			 the date of service. Every member visit or telephone call with the staff must
			 be recorded. The documentation must include the reason for each visit or
			 telephone call and any action taken.
(B) The medical record must contain, but is
			 not limited to, the following information:
(1) the member's name, address, telephone
			 number, date of birth, and MassHealth identification number;
(2) the date of service;
(3) the name, title, and signature of the
			 person performing the service or making the contact;
(4) the type of visit (for example, annual or
			 routine);
(5) medical history and
			 history update;
(6) pertinent
			 findings on examination;
(7)
			 laboratory tests and results;
(8)
			 abnormal findings and follow-up treatment;
(9) drugs administered or prescribed,
			 including strength, dosage, route, regimen, and number of refills;
(10) drugs dispensed, including strength,
			 dosage, route, regimen, and number of units;
(11) the contraceptive method used and any
			 special instructions;
(12) a
			 summary of counseling; and
(13)
			 plans for follow-up.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 421.000 - Family Planning Agency Services › Section 421.424 - Quality Assurance

Current through Register 1525, July 5, 2024
(A)
Medical
.
(1) The
			 medical director or his or her designee must perform an on-site review of all
			 physicians, nurse practitioners, and physician assistants within the first
			 three months of their employment and thereafter annually for physicians and
			 semiannually for nurse practitioners and physician assistants. Written reports
			 of these reviews must be included in the personnel file. The on-site review
			 must include observation and assessment of the clinical skills of the
			 practitioner in caring for a variety of patients.
(2) The medical director or his or her
			 designee must review at least four times a year a sample of the agency's
			 records for adequacy of documentation and appropriateness of treatment and
			 follow-up.