Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 104 - MAINE STATE SERVICES MANUAL › Sec2 144-104-6 - Independent Practice Dental Hygienist Services › Subsection 144-104-6.07 - PROVIDER REIMBURSEMENT

Current through 2024-29, July 17, 2024
A.
IPDH
				  Services Provided in Non-FQHC Settings
: will be reimbursed according to
				  the following chart, including any restrictions listed in the chart, so long as
				  the eligibility and other requirements of this regulation are met.
B.
IPDH Services Provided in FQHC
				  Settings
: will utilize the following chart, including any restrictions
				  listed in the chart, except that FQHCs will not utilize the reimbursement rate
				  that is listed in the Chart. So long as the eligibility and other requirements
				  of this regulation are met, reimbursement for these services is as follows:
1. If the FQHC was reimbursed by MaineCare,
				  on the date of service, for an ambulatory clinic visit for the Member, then the
				  FQHC is not eligible for reimbursement for a Section 6 IPDH service on that
				  date.
2. The reimbursement rate
				  for FQHCs for IPDH services will be that FQHC's MaineCare ambulatory clinic
				  visit rate that was in effect on the date the IPDH service was delivered.
Covered Service
Age/ICF-MR
Proc.
Code
Description
under age 21 & all ICF-IID
								residents
age 21 & over when allowed under MBM Chap
								II, Sec 25.04
Additional Limits
Max Allow for IPDH services in non-FQHC
								settings
D0210
Intraoral - Complete Series of Radiographic
								Images
YES
YES
Must include 12 periapical plus 2 posterior
								bitewings, allowed only once every 3 years, except as part of approved
								orthodontics.
$43.50
D0220
Intraoral - Periapical, First Radiographic
								Image
YES
YES
$8.00
D0230
Intraoral - Periapical, Each Additional
								Radiographic Image
YES
YES
$6.50
D0240
Intraoral - Occlusal Radiographic Image
YES
YES
$10.00
D0250
Extraoral - First Radiographic Image
YES
YES
$9.00
D0260
Extraoral - Each Additional Radiographic
								Image
YES
YES
$9.00
D0270
Bitewing - Single Radiographic Image
YES
YES
Posterior bitewings alone are once per calendar
								year.
$8.00
D0272
Bitewings - Two Radiographic Images
YES
YES
Posterior bitewings alone are once per calendar
								year.
$15.00
D0273
Bitewings - Three Radiographic Images
YES
YES
Posterior bitewings alone are once per calendar
								year .
$17.50
D0274
Bitewings - Four Radiographic Images
YES
YES
Posterior bitewings alone are once per calendar
								year.
$20.00
D0277
Vertical Bitewings - 7-8 Radiographic Images
YES
YES
$30.00
D0330
Panoramic Radiographic Image
YES
YES
Reimbursable: (1) for interceptive orthodontics;
								(2) for oral surgery; (3) once per five (5) years when used in conjunction with
								any Preventative Service or Diagnostic Service (as defined in MaineCare
								Benefits Manual Ch. III Sec 25 ). .
$43.00
D1110
Prophylaxis - Adult
YES
YES
Limited to age 13 and over. Twice per calendar
								year, but no more than once every 150 days. Includes oral hygiene instruction.
								IPDHs may use this code only for members up to age 21.
$40.00
D1120
Prophylaxis - Child
YES
NO
Twice per calendar year, but no more than once
								every six months requires 150 days. Includes oral hygiene instruction.
$30.00
D1206
Topical Application of Fluoride Varnish
YES
NO
For members under age 3, twice per calendar year.
								For members age 3 through age 20, twice per calendar year but no more than once
								every 150 days. Third per calendar year for all members through age 20
								permitted if high caries rate or new restorations within 18 months as
								documented in record.
$12.00
D1208
Topical Application of Fluoride
YES
NO
For members under age 3, twice per calendar year.
								For members age 3 through age 20, twice per calendar year but no more than once
								every 150 days. Third per calendar year for all members through age 20
								permitted if high caries rate or new restorations within 18 months as
								documented in record.
$12.00
D1330
Oral Hygiene Instructions
YES
NO
Three times per calendar year. Not billable the
								same day as prophylaxis.
$13.00
D1351
Sealant - Per Tooth
YES
NO
Permanent teeth: once every three calendar years
								per tooth. Primary teeth: once per lifetime of tooth unless documented good
								cause.
$16.00
D2940
Protective Restoration
YES
YES
Not covered with Pulpotomy.
$30.00