Dental Services - MassHealth ACO Payment Policy
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Defines Fallon Community Health Plan's reimbursement, coverage, billing, prior authorization, and documentation expectations for dental services affecting MassHealth ACO members and providers furnishing dental, oral/maxillofacial surgery, and maxillofacial prosthetics services.
No material clinical or coverage changes in this revision.
Coverage Criteria for Dental, Oral/Maxillofacial Surgery, and Prosthetics
Emergency services coverage
Covered when ALL of the following are met:
Oral and maxillofacial surgery coverage
Covered when ALL of the following are met:
Maxillofacial prosthetics coverage
Covered when ALL of the following are met:
Facility/anesthesia coverage and documentation requirements
Covered when ALL of the following are met:
Indications (ONE or more):
- Member has a condition reasonably likely to place them at risk of medical complications requiring resources not available in an office setting.
- Member is extraordinarily uncooperative, fearful, or anxious such that safe care cannot be delivered in the office.
- Local anesthesia is ineffective due to acute infection, idiosyncratic anatomy, or allergy.
- Member has sustained orofacial or dental trauma so extensive treatment cannot be provided safely and effectively in the office.
Applicable Codes and Claim Form Requirements
| CPT codes listed in Subchapter 6 Section 615 of the MassHealth Dental Manual | CPT codes payable by Fallon Health for oral/maxillofacial surgery and maxillofacial prosthetics when provided by appropriately credentialed providers. |
| CDT codes | Current Dental Terminology codes — must be submitted to MassHealth; not reimbursed by Fallon Health for MassHealth ACO members. |
Provider Obligations, Prior Authorization, and Tools
Prior authorization required for OMS services, prosthetics, and facility charges
Oral and maxillofacial surgery services and maxillofacial prosthetics may require prior authorization; facility charges reimbursed by Fallon Health (acute outpatient hospital/ASC facility fees, anesthesia fees, etc.) require prior authorization and are subject to medical necessity review.
- Includes oral and maxillofacial surgery and maxillofacial prosthetics
- Facility charges reimbursed by Fallon Health (acute outpatient hospital and ambulatory surgical center facility fees, anesthesia fees, etc.) require prior authorization
Obtain prior authorization for facility/anesthesia when hospital/ASC is medically necessary
Plan prior authorization is required for facility and other related charges (including anesthesia) when an acute outpatient hospital or ambulatory surgical center setting is medically necessary for safe delivery of dental procedures.
- Applies when hospital/ASC setting is medically necessary for restorative, endodontic, or exodontic procedures
- Claims for dental services billed with CDT codes must still be submitted to MassHealth even when performed in a hospital/ASC
Check the Fallon Health Procedure code look‑up for PA requirements
Use the Fallon Health Procedure code look‑up tool on the Fallon Health providers site to determine whether a specific procedure requires prior authorization.
- Tool available at https://fallonhealth.org/en/providers
- Note: the Plan cannot authorize services not reimbursed by Fallon (e.g., CDT-billed dental services reimbursed by MassHealth); facility charges reimbursed by Fallon still require PA and medical necessity review
Definitions and Provider Qualifications
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.