Provider Eligibility In-state and Out-of-state

(A) In-state Providers. The following requirements apply when the dental provider’s practice is located in Massachusetts. (1) Dental Practitioner. A dentist engaged in private practice is eligible to participate in MassHealth as a dental provider if licensed to practice by BORID. Private practices may include, but are not limited to, solo, partnership, or group practices. (2) Community Health Center. A licensed community health center with a dental clinic is eligible to participate in MassHealth as a provider of dental services. (3) Dental School. A teaching clinic of a dental school accredited by CODA is eligible to participate in MassHealth as a provider of dental services. (4) Acute Hospital Outpatient Department, Hospital-licensed Health Center, or Other Satellite Clinic. An acute hospital’s outpatient department, hospital-licensed health center, or other satellite clinic that participates in MassHealth pursuant to the Executive Office of Health and Human Services (EOHHS) Acute Hospital Request for Applications (RFA) and contract is eligible to provide services designated as dental clinic services in Subchapter 6 of the MassHealth Dental Manual for providers under 130 CMR 420.000. (5) Dental Clinic. A dental clinic must be licensed by the Massachusetts Department of Public Health (DPH) to be eligible to participate in MassHealth as a dental provider. A DPH license is not required for a state owned and operated dental clinic. A dental clinic that limits its services to education and diagnostic screening is not eligible to participate in MassHealth as a dental provider. (6) Specialist in Orthodontics. A dentist who is a specialist in orthodontics must have completed a minimum of two years' training in a CODA advanced-education program in orthodontics that fulfills all educational requirements for eligibility for the examination by the American Board of Orthodontists. (7) Specialist in Oral Surgery. A dentist who is a specialist in oral surgery must have completed a minimum of four years' training in an oral and maxillofacial surgery advanced-education program, fulfilling the requirements for advanced training in oral and maxillofacial surgery as outlined by CODA and leading to a Certificate of Advanced Graduate Studies (CAGS). (8) Other Dental Specialists. A dentist who is a specialist in any other area of dentistry (for example, pedodontics, anesthesiology, endodontics, periodontics, or prosthodontics) must have completed the appropriate CODA-accredited certificate program that satisfies eligibility requirements for the specific specialty board. (9) Public Health Dental Hygienist. A dental hygienist engaged in private practice is eligible to participate in MassHealth as a dental provider and claim payment for certain services without the direct supervision of a dentist if he or she is licensed to practice as a registered dental hygienist by BORID and also meets the board’s requirements to practice in a public health setting pursuant to 234 CMR 2.00: General Rules and Requirements et seq. Private practices may include, but are not limited to, solo, partnership, or group practices. (10) Mobile Dental Facility (MDF) or Portable Dental Operation (PDO). A dentist or public health dental hygienist is eligible to participate in MassHealth as a dental provider and claim payment for certain services provided through a MDF or PDO only if the provider satisfies the requirements of 234 CMR 7.00: Mobile and Portable Dentistry and has obtained a valid permit as a MDF or PDO from BORID. (B) Out-of-state Providers. A dental provider whose practice is located outside of Massachusetts is eligible to participate in MassHealth as a dental provider and to be paid for dental services provided to MassHealth members only if the provider is licensed or certified by the state in which the provider practices, meets the specific provider eligibility requirements listed in 130 CMR 420.404, and meets the conditions set forth in 130 CMR 450.109: Out of State Services. (C) Enhancement Fee for Community Health Centers and Hospital-licensed Health Centers. (1) To qualify for an enhancement fee for dental services, community health centers and hospital-licensed health centers must commit to undertaking efforts that include, but are not limited to, increasing access to dental-covered services by implementing and reporting on measures to increase the capacity and volume of dental services they deliver, either directly or through subcontracts with private dental providers. (2) The dental enhancement fee is set by the Executive Office of Health and Human Services (EOHHS) (see 101 CMR 314.00: Dental Services).