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 2024-38, September 18, 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:
|
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 |
