Section 314.03 - Rate Provisions(1)Rate Determination. Subject to 101 CMR 314.03(2) and (3), rates of payment for authorized dental services to which 101 CMR 314.00 applies will be the lower of(a) the eligible dentist provider's usual and customary fee to patients other than publicly aided individuals; or(b) the allowable fee listed in 101 CMR 314.04, 314.05, or 314.06, as applicable.(2)Rates Determination for EPSDT-eligible MassHealth Members. Rates of payment for authorized dental services to which 101 CMR 314.05 applies provided by eligible dental providers to EPSDT-eligible MassHealth members will be the allowable fee (EPSDT-eligible members) listed in 101 CMR 314.05.(3)Individual Consideration (I.C.).(a) Unlisted procedures and dental procedures designated I.C. are individually considered items. Determination of appropriate payment for procedures designated I.C. will be in accordance with the following standards and criteria: 1. time required to perform the procedure;2. degree of skill required in the procedure performed;3. severity and/or complexity of the patient's dental disease or condition; and4. policies, procedures and practices of other third-party purchasers of dental services, both governmental and private.(b) If an eligible provider believe that any such procedure merits a higher fee than recommended, the provider may submit the prescribed claim form with supporting documentation. Such claims will be individually processed.(4)Reimbursement as Full Payment. Each eligible dental provider must, as a condition of acceptance of payment made by any purchasing governmental units for services rendered, accept the approved program rates as full payment and discharge of all obligations for the services rendered. Payment from any other source will be used to offset the amount of the purchasing governmental unit's obligation for services rendered to the publicly aided individual.(5)Payment Limitations. No purchasing governmental unit may pay less than or more than the approved program rate.(6)Prior Authorization. A number of procedures require authorization from the appropriate purchasing agency before providing the service and before payment will be made. Eligible dental providers should refer to the appropriate purchasing agency manual before providing services.Adopted by Mass Register Issue 1342, eff. 6/30/2017.Amended by Mass Register Issue 1366, eff. 2/15/2018.Amended by Mass Register Issue 1375, eff. 10/5/2018.Amended by Mass Register Issue 1455, eff. 10/15/2021.Amended by Mass Register Issue 1462, eff. 10/15/2021.Amended by Mass Register Issue 1486, eff. 1/1/2023 (EMERGENCY).Amended by Mass Register Issue 1492, eff. 1/1/2023 (EMERGENCY).Amended by Mass Register Issue 1496, eff. 1/1/2023 (COMPLIANCE).Amended by Mass Register Issue 1524, eff. 6/21/2024.