130 CMR, § 420.422

Current through Register 1536, December 6, 2024

Section 420.422 - Service Descriptions and Limitations: Diagnostic Services

(A)Comprehensive Oral Evaluation. The MassHealth agency pays for a comprehensive oral evaluation once per member, per provider or per location. A comprehensive oral evaluation is more thorough than a periodic oral evaluation, and includes a written review of the member's medical and dental history, the examination and charting of the member's dentition and associated structures, periodontal charting if applicable, diagnosis, and the preparation of treatment plans and reporting forms. It is a thorough evaluation and recording of the extraoral and intraoral hard and soft tissues.

(B)Periodic Oral Evaluation. The MassHealth agency pays for a periodic oral evaluation twice per calendar year, per member, per provider or location. This service is not covered on the same date of service as a palliative emergency treatment visit. A periodic oral evaluation is performed on an established patient of record to determine any changes in the member's dental and medical health status since a previous comprehensive or periodic oral evaluation.

(C)Oral Evaluation. The MassHealth agency pays for this service twice per calendar year per provider or location. An oral evaluation is counseling with a primary caregiver (parent/guardian) for members younger than three years old.

(D)Limited Oral Evaluation. The MassHealth agency pays for a limited oral evaluation twice per member per calendar year. A limited oral evaluation is not covered on the same date of service as a palliative emergency treatment visit. A limited oral evaluation is an evaluation limited to a specific oral health problem or complaint. This may require interpretation of information acquired through additional diagnostic procedures. Typically, patients receiving this type of evaluation are present with a specific problem and/or dental trauma, pain, or acute infection.

(E)Comprehensive Periodontal Evaluation. The MassHealth agency pays for a comprehensive periodontal evaluation once per calendar year per member per provider or per location. A comprehensive periodontal evaluation is indicated for members showing signs or symptoms of periodontal disease and for members with risk factors such as smoking or diabetes. A comprehensive periodontal evaluation includes evaluation of periodontal conditions, probing and charting, evaluation and recording of dental caries, missing or unerupted teeth, restorations, occlusal relationships and oral cancer evaluation.

(F)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.

(G)Limited Clinical Assessment. The MassHealth agency pays for a limited clinical assessment 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.