Individual Consideration

(A) Certain services, including unspecified procedures, are designated "IC" (individual consideration) in Subchapter 6 of the Dental Manual and in the EOHHS pricing regulation for dental services, 101 CMR 314.00: Dental Services. This means that a fee could not be established for these services. The MassHealth agency determines appropriate payment for individual consideration services from the provider's detailed report of services provided (see Subchapter 6 of the Dental Manual for report requirements). The MassHealth agency does not pay claims for "IC" services without a complete report (see 130 CMR 420.415). If the documentation is illegible or incomplete, the MassHealth agency denies the claim. (B) The MassHealth agency determines the appropriate payment for an individual-consideration service in accordance with the following standards and criteria: (1) the amount of time required to perform the service; (2) the degree of skill required to perform the service; (3) the severity and complexity of the member's disease, disorder, or disability; and (4) any extenuating circumstances or complications.