Health Safety Net Dental Program Commonwealth Of .

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Serving the Health Safety Net Program*Health Safety Net Dental ProgramCommonwealth of MassachusettsJanuary 15, 2021Office Reference ManualCHC’s, HLHC’s, & Acute Hospital Outpatient Departments465 Medford StreetBoston, MA ealth Dental Program April 2, 2021Current Dental Terminology American Dental Association. All Rights Reserved.

Health Safety Net Dental ProgramServing the Health Safety NetProgram*2Health Safety Net Dental ProviderQuick Reference Directorymasshealth-dental.netProvider ServicesEligibility, Claim Submission & StatusPhone Number1.800.207.5019TDD (Hearing Impaired)Health Safety Net Help DeskFor questions about HSN policy, INET,Dental, HSN remittances on HSN claimpayments.AuthorizationsPrior Authorizations (PA)1.800.466.7566ClaimsPaper Claims Submission90 Day Waiver/Final Deadline WaiverRequestElectronic ClaimsEDI Claims Submission(837DTransactions) and RemittanceAdviceVia Website atwww.masshealth-dental.netVia ClearinghousePayer ID CKMA1Provider Complaints and FraudProvider ComplaintsFraud Hotline1.800.609.7232E-mail s1.800.207.50191.800.207.5019Mailing AddressDentaQuestHealth Safety Net- Eligibility &ServicesP.O. Box 2906Milwaukee, WI 53201-2906Health Safety Net Dental – PAP.O. Box 2906Milwaukee, WI 19Health Safety Net Dental – ClaimsP.O. Box 2906Milwaukee, WI 53201-2906Health Safety Net Dental – 90 Dayand Final Deadline Waiver/Requests465 Medford StreetP.O. Box 9708Boston, MA 207.50191.800.237.9139masshealth-dental.netHealth Safety Net Dental – ClaimsP.O. Box 2906Milwaukee, WI 53201-2906Health Safety Net Dental – ClaimsP.O. Box 2906Milwaukee, WI 53201-2906***The Health Safety Net offers you the ability to submit HIPAA-compliant claims to: www.masshealth-dental.net. You may also submit claimsthrough an approved clearinghouse trading partner. Please contact your software vendor to ensure that the Health Safety Net is listed as a payer.The HSN is CKMA1. For greater detail, please contact Customer Service at: 1-800-207-5019 or your Provider Relations Representative.HSN Team at DentaQuestTracy Gilman (Chase)Sean MoranDaniel ArchambaultKeishia LopezAdeola veley@dentaquest.comRegional Director, MassHealthProvider Intervention SpecialistProvider Relations RepresentativeProvider Relations RepresentativeProvider Relations RepresentativeThank you to all of the providers who currently participate with the Health Safety Net. Your commitment to serving your community and providingthe best possible care to our patients is greatly appreciated. Our goal is to continue to raise the bar in terms of customer service. Please reach outany time you have concerns, suggestions, or praise, as we continue to work together to promote oral health within the Commonwealth ofMassachusetts.Sincerely,The Health Safety Net Team at DentaQuest*DentaQuest is the subcontractor to Dental Service of Massachusetts, Inc.MassHealth Dental Program April 2, 2021Current Dental Terminology American Dental Association. All Rights Reserved.

Health Safety Net Dental Program3Health Safety Net Dental ProgramThe Health Safety Net (HSN) makes payments to Massachusetts hospitals and community health centers forhealth care services provided to low-income Massachusetts residents who are uninsured or underinsured. TheHSN is administered by the Office of Medicaid within the Executive Office of Health and Human Services.The Health Safety Net pays for the same set of dental services that are covered by MassHealth Standard, pluscertain services which used to be covered by MassHealth but are not currently covered by MassHealth.Patients may be determined eligible only for the HSN or may be determined eligible for MassHealth with HSNas a secondary payer for certain services. The Health Safety Net prices dental services using MassHealth’sdental fee schedule.As of November 2016, DentaQuest administers the Health Safety Net Dental program. HSN dental providerssubmit dental claims directly to DentaQuest for processing and pricing. The Health Safety Net makes a monthlypayment to providers, which includes payment for both medical and dental services.This Office Reference Manual provides important information for HSN providers about eligible dental services,claims, clinical criteria, and other processes.***The Health Safety Net Dental Program makes every effort to maintain accurate information in this manual;however, the Health Safety Net Dental Program and its administrator will not be held liable for any damagesdirectly or indirectly due to typographical errors. Please contact us should you discover an error.MassHealth Dental Program April 2, 2021Current Dental Terminology American Dental Association. All Rights Reserved.

Health Safety Net Dental Program4Office Reference ManualTable of 15.0515.0615.0715.08PageProvider Services. 8Dedicated Call Center for Dental Providers . 8Provider Training . 8Provider Web Portal . 9Provider Directory. 9Eligibility Verification Procedures . 9Health Safety Net Dental Program . 9Health Safety Net Dental Program Eligibility System . 9Authorization for Treatment . 11Prior Authorization Request for CPT Codes . 11Eligible Services Requiring Authorization . 111Authorization for Operating Room (OR) Cases . Error! Bookmark not defined.2Payment for Non-Eligible Services . 13Electronic Attachments . 133Orthodontic . 144Transfer or Release of Authorization . 144Claim Submission Procedures (Claim Filing Options . 155Electronic Claim Submission through Direct Data Entry. 156Electronic Claim Submission via Upload to www.masshealth-dental.net . 166Electronic Claim Submission via Clearinghouse . 166Requirements for Claim Submission . 166Third Party Liability (TPL) . 17Filing Limits . 19Remittance Information . 200Claim Submission and Payment for Operating Room (OR) Cases . 200Claim Submission for CPT Codes . 200Billing Low Income Patients and MassHealth Patients . 211Member Complaints . 222Utilization Management Program . 233Introduction . 233The Patient Record – See HSN Regulations . 244Medical Record Requirements . 244Patient Recall System . 255Recall System Recommendation . 255Intervention Services Program . 266Dedicated Intervention Specialists . 266Appointment Assistance . 266Radiology Requirements . 27Clinical Criteria . 300Dental Extractions . 311Cast Crowns. 311Endodontic Treatment . 322Stainless Steel Crowns . 333Operating Room . 334Removable Prosthodontics (Full and Partial Dentures). 344Determination of a Non-Restorable Tooth . 355Criteria for General Anesthesia and Intravenous (IV) Sedation . 356MassHealth Dental Program April 2, 2021Current Dental Terminology American Dental Association. All Rights Reserved.

Health Safety Net Dental ntal Treatment . 37Orthodontic Eligibility . 39Authorization for Comprehensive Orthodontic Treatment . 39Authorization Determination . 41Authorization Extension . 42Authorization for Continuation of Care . 44Authorization for Interceptive Orthodontic Treatment. 44Additional Resources . 47APPENDIX AGeneral Definitions . A-1APPENDIX B Sample FormsAuthorization Form for Comprehensive Orthodontic Treatment . B-1Medical Necessity Narrative . B-3Handicapping Labio-Lingual Deviation Index Scoring Instructions B-5Orthodontic Continuation of Care Form. B-7Instructions for Dental Claim Form . B-8Void Request Form . B-10Initial Clinical Exam . .B-11Recall Examination Form. B-12Medical and Dental History . B-14APPENDIX CQuick Reference FlyersThird Party Liability . C-1Corrective Action for Denied Claims . C-2Corrective Action for Incorrectly Paid Claims . C-3Overpayments on Claims . C-4APPENDIX D Covered Services (See Exhibits A-F)Eligible Services . D-1APPENDIX EOrthodontics . . E-1Radiographs . E-1MassHealth Dental Program April 2, 2021Current Dental Terminology American Dental Association. All Rights Reserved.

Health Safety Net Dental Program6What is the Health Safety Net Dental Program?The Health Safety Net Dental Program is based upon Commonwealth of Massachusetts regulations governingdental services found in 101 CMR 613.00 and 101 CMR 614.00. All Acute Hospitals, Community Health Center(CHC), and Hospital Licensed Health Centers (HLHC) must comply with these regulations. Please refer to theHealth Safety Net web page at www.mass.gov/healthsafetynet for additional information and regulations. Ifthere is a conflict between the Office Reference Manual and the regulations, the regulations take precedencein every case.Health Safety Net Eligibility & Reimbursable Service ProvisionsEligible Services Categories There are three categories of services eligible for payment from the Health Safety Net,as follows:1. Reimbursable Health Services to Low Income Patients as defined in 101 CMR 613.04;2. Medical Hardship, pursuant to the requirements in 101 CMR 613.05; and3. Bad Debt, pursuant to the requirements in 101 CMR 613.06.Low Income Patients“Low Income Patient” is the term used in Health Safety Net regulations to refer to a Health Safety Net patient. TheHealth Safety Net pays for Reimbursable Health Services provided to Low Income Patients for services providedduring the Eligibility Period specified in 101 CMR 613.04(5). The Eligibility Period usually starts ten days before thedate of application.Reimbursable Health ServicesThe Health Safety Net pays only for the Reimbursable Health Services listed in this Office Reference Manual.Providers may submit claims only for Reimbursable Health Services provided by Acute Hospitals and CommunityHealth Centers in accordance with the MassHealth Standard program using the payment codes as listed inSubchapter 6 of the MassHealth Inpatient and Outpatient Provider Manuals and other MassHealth Providermanuals unless otherwise specified in 101 CMR 614.00: Health Safety Net Payments and Funding.Acute HospitalsThe Health Safety Net pays acute hospitals and HLHC’s only for dental services identified in Subchapter 6 of theMassHealth Dental Manual and for Adult Dental Services not covered by MassHealth, as further clarified inAppendix D of this Office Reference Manual.Community Health CentersThe Health Safety Net pays CHCs only for dental services identified in Subchapter 6 of the MassHealth DentalManual and for Adult Dental Services not covered by MassHealth, as further clarified in Appendix D of this OfficeReference Manual.Community Health Centers may submit claims only for services provided under the Community Health Center’sclinic license. A Community Health Center may submit claims only for dental services provided on site, with theexception that a Community Health Center may submit claims for dentures provided on site but manufactured orrepaired at an off-site contractor.MassHealth Dental Program April 2, 2021Current Dental Terminology American Dental Association. All Rights Reserved.

Health Safety Net Dental Program7Reimbursable Health Services LimitationsThe Health Safety Net does not pay for any of the following services: nonmedical services, such as social,educational, and vocational services; cosmetic surgery; canceled or missed appointments; telephoneconversations or consultations; court testimony; research or the provision of experimental, cosmetic, unproven, orotherwise medically unnecessary procedures or treatments.Health Safety Net-Dental Plan TypesHSN Adult – HSN will pay for all HSN eligible dental services that are allowable for adults. Patients may qualifyonly for the HSN, or may also be enrolled in: Private InsuranceConnectorCareMedicareStudent Health InsuranceThe Children’s Medical Security Program (CMSP)

The Health Safety Ne t Dental Program is based upo n Commonwealth of Massachuset ts reg ulations governing dent al services found i n 101 CMR 613.0 0 and 101 CMR 614.00 . All Acute Hospitals, Communit y Health Center

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