Dental Services Fallon Medicare Plus and NaviCare Payment Policy
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Defines Fallon Community Health Plan's reimbursement and prior authorization rules for dental services provided to Fallon Medicare Plus and NaviCare HMO SNP members, including when Medicare may pay and how supplemental dental benefits are administered.
Effective January 1, 2026, NaviCare HMO SNP includes coverage for dental services as Medicare supplemental benefits.
For claims received on and after 07/01/2025, dental service claims must include the KX modifier or they will be denied, and must include a valid ICD-10 diagnosis code.
DentaQuest is Fallon Health's dental vendor effective January 1, 2024, and prior authorization requests and claims must be submitted to DentaQuest.
When Dental Services Are Reimbursable
When dental services are reimbursable
Covered when the following criteria are met:
ALL of the following
ONE of
ALL of the following
- Patient requires hospitalization because the patient’s underlying medical condition/clinical status or the severity of the dental procedure requires hospitalization in compliance with section 1862(a)(12) of the Social Security Act
Reimbursement consistent with statutory authority; may be inpatient or outpatient as clinically appropriate.
ALL of the following
- Dental service is substantially related and integral to the clinical success of another Medicare-covered medical service
Examples include pre‑procedure dental/oral exams and treatment to eliminate infection prior to organ transplant, cardiac valve replacement, chemotherapy/CAR T‑cell therapy, head and neck cancer treatment, dialysis for ESRD, dental ridge reconstruction concurrent with tumor removal, stabilization of teeth for jaw fracture, and dental splints when part of covered medical treatment; CMS examples are not exhaustive (see guidance).
ALL of the following
- Anesthesia, diagnostic x‑rays, operating room use, and other related procedures may be reimbursed when incident to a covered dental service
Applies whether services are performed inpatient or outpatient.
ALL of the following
AT LEAST ONE of
- Evidence that standard of care is to delay the covered medical procedure until dental/oral exam clears infection or necessary dental treatment is performed
May include clinical guidelines, peer‑reviewed literature, or other supporting documentation.
- Literature or clinical evidence demonstrating that the dental service materially improves clinical outcomes of the medical procedure (e.g., improved healing, fewer revisions or readmissions, more rapid recovery).
ALL of the following
- There is exchange of information or coordination (for example, referral or documentation exchange) between the dentist and the medical professional treating the primary medical condition
Without such integration an inextricable link is not established and services may be excluded from Medicare Part B coverage.
ALL of the following
ANY of the following
- Inpatient hospital services connected to noncovered dental services require prior authorization
Prior authorization requests and claims must be submitted directly by the treating dentist to DentaQuest; see DentaQuest enrollment resources.
- Dental services inextricably linked to covered medical services generally do not require prior authorization, although some related services or supplies may require authorization.
ALL of the following
- For claims received on or after 07/01/2025 include the KX modifier on each claim line and a valid ICD‑10 diagnosis code
Claims without the required KX modifier or ICD‑10 will be denied; KX indicates documentation supports that dental services are inextricably linked to a covered medical service.
ALSO
ALL of the following
- Certain Fallon Medicare Advantage plans offer supplemental dental benefits as described in the Evidence of Coverage and Dental Addendum
NaviCare HMO SNP includes supplemental dental coverage effective 01/01/2026; see plan‑specific documents for benefit limits and network details.
Billing and Coding Requirements
| KX | Modifier to indicate documentation supports that dental services are inextricably linked to a covered medical service |
Prior Authorization, Submission, and Billing Actions for Providers
Submit prior authorization requests and claims directly to DentaQuest
Some dental services require prior authorization and all prior authorization requests and dental claims must be submitted directly by the treating dentist to DentaQuest. Dentists should use DentaQuest enrollment resources for authorizations and claims submission and may contact DentaQuest at https://www.dentaquest.com/en/providers/massachusetts for information.
- Requests for prior authorization must be sent directly by the treating dentist to DentaQuest for review.
- Claims for dental services must be submitted by the treating dentist to DentaQuest.
- DentaQuest provider resources and enrollment information: https://www.dentaquest.com/en/providers/massachusetts
Prior authorization required for inpatient services linked to noncovered dental care
Obtain prior authorization for inpatient hospital services that are provided in connection with noncovered dental services. Dental services that are inextricably linked to covered medical services do not require prior authorization, though some related services or supplies may still require prior authorization.
- Prior authorization is required for inpatient hospital services connected to noncovered dental procedures.
- No prior authorization is required for dental services determined to be inextricably linked to and substantially related and integral to a covered medical service, but related services/supplies may require authorization.
Include KX modifier and valid ICD-10 on claims on/after 07/01/2025
For claims received on or after 07/01/2025, include the KX modifier on each claim line and submit a valid ICD-10 diagnosis code; claims without the KX modifier will be denied and dental claims will reject if not submitted with a valid ICD-10.
- Effective 07/01/2025 include the KX modifier on every claim line to expedite inextricable linkage determinations.
- Claims for dental services received on or after 07/01/2025 submitted without the KX modifier will be denied.
- Dental claims received on or after 07/01/2025 will reject if not submitted with a valid ICD-10 diagnosis code.
Key Definitions
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