Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 420.000 - Dental Services
Section 420.413 - Separate Procedures
Current through Register 1531, September 27, 2024
Certain procedures are designated "SP" (separate procedure) in the service descriptions in Subchapter 6 of the Dental Manual. A separate procedure is one that is commonly performed as an integral part of a total service and therefore does not warrant a separate payment, but that commands a separate payment when performed as a separate procedure not immediately related to other services. For example,
(A) the MassHealth agency does not pay for a frenulectomy when it is performed as part of a vestibuloplasty, and full-study models are not payable separately when performed as part of orthodontic treatment or diagnosis. Nevertheless, the MassHealth agency does pay for frenulectomy as a separate procedure when medically necessary; and
(B) the MassHealth agency does not pay for restorations placed on two or more surfaces within 12 months on the same tooth as separate restorations at the one-surface rate. Claims submitted as separate restorations will be paid at the appropriate multi-surface restoration rates set by EOHHS at 101 CMR 314.00: Dental Services, subject to the conditions, exclusions, and limitations set forth in 130 CMR 420.000 and 130 CMR 450.000: Administrative and Billing Regulations.
