Chapter 05. Dental Services
Regulation .01 Definitions.LinkCopy Citation
A.
In this chapter, the following terms have the meanings indicated.
B.
Terms Defined.
(1)
“Adverse action” means any action taken by the DASO to deny, reduce, terminate, delay, or suspend a covered service.
(2)
“Aftercare” means the period of follow-up care after initial services are rendered, during which any additional related services rendered by the same provider are included in the payment for the original services.
(3)
“Ambulatory surgical center (ASC)” means any Medicare-certified entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization.
(4)
“Appeal” means the process:
(a)
To resolve a participant's dispute with any adverse action taken by the DASO to deny, reduce, terminate, delay, or suspend a covered service; and
(b)
Governed by:
(i)
COMAR 10.01.04; and
(ii)
Any and all applicable court orders.
(5)
“Benefits” means a schedule of dental services to be administered by the DBA to Medical Assistance participants pursuant to this chapter.
(6)
“Brick and mortar dental office” means the fixed and permanent location where the mobile dental unit:
(a)
Is linked through either ownership or a legally binding contract; and
(b)
Transmits participant records.
(7)
“Claim” means an itemized statement requesting payment for services rendered by health care providers, such as dentists, billed:
(a)
Electronically;
(b)
Through a web-based portal; or
(c)
Manually on the American Dental Association (ADA) claim form.
(8)
“Consultation” means written opinion or advice rendered by a dentist, upon request by the patient's attending physician or dentist, for the further evaluation or management of the patient by the attending physician or dentist. If the consultant dentist assumes responsibility for the continuing care of the patient, a subsequent service rendered by the consultant is not a consultation.
(9)
“Dental Administrative Services Organization (DASO)” means an entity with which the Department contracts to administer dental benefits by performing some or all of the following functions:
(a)
General administration;
(b)
Regulatory compliance;
(c)
Network administration;
(d)
Member services;
(e)
Claims administration;
(f)
Data reporting and analysis;
(g)
Medical management; or
(h)
Quality monitoring.
(10)
“Dental services” means emergency, preventive, or therapeutic services for oral diseases which are administered by or under the general supervision of a dentist in the practice of the profession.
(11)
“Department” means the Maryland Department of Health, the single State agency designated to administer the Maryland Medical Assistance Program under Title XIX of the Social Security Act, 42 U.S.C. §§1396 et seq., or the Department's designee.
(12)
“Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)” means comprehensive and preventive health care pursuant to 42 U.S.C. §1396d(e) as amended by OBRA 1989.
(13)
“Emergency services” means services necessary for the treatment of any condition requiring immediate attention for the relief of pain, hemorrhage, acute infection, or traumatic injury to the teeth, supporting structures (that is, periodontal membranes, gums, and alveolar bone), the jaws, and tissues of the oral cavity.
(14)
“EPSDT certified provider” means a physician, physician assistant, or nurse practitioner certified by the Department to provide EPSDT services.
(15)
“Free-standing clinic” means a health care facility approved for participation in the Maryland Medical Assistance Program that is not licensed as a hospital or as part of a hospital or nursing home and that is not administratively part of a health maintenance organization or physician's, dentist's, or osteopath's office, but which has a separate staff functioning under the direction of the clinic administrator (as defined in 42 CFR §405.1801) or a health officer and which is organized and operated to provide clinic services.
(16)
“General supervision” has the meaning stated in COMAR 10.44.21 and 10.44.27.
(17)
“Hospital” has the meaning stated in Health-General Article, Title 19, Subtitle 3, Annotated Code of Maryland.
(18)
“Maryland Healthy Smiles Dental Program” means the Maryland Medicaid dental program.
(19)
“Medical Assistance Program” means the program of comprehensive medical and other health-related care for indigent and medically indigent persons.
(20)
“Medically necessary” means that a service or benefit is:
(a)
Directly related to diagnostic, preventive, curative, palliative, rehabilitative, or ameliorative treatment of an illness, injury, disability, or health condition;
(b)
Consistent with currently accepted standards of good medical practice, dental practice, or both;
(c)
The most cost effective service that can be provided without sacrificing effectiveness or access to care; and
(d)
Not primarily for the convenience of the consumer, family, or provider.
(21)
“Medicare” means the insurance program administered by the Federal government under Title XVIII of the Social Security Act, 42 U.S.C. §§1395 et seq.
(22)
“Mobile dental unit” means any self-contained facility in which dentistry will be provided and which may be moved, towed, or transported from one location to another to provide clinically necessary and appropriate dental care in the unit.
(23)
“Mobile dental practice” means any practice which provides the necessary and clinically appropriate dental equipment to be delivered to a community based location where dental services will be provided on site.
(24)
“Network provider” means a health care entity or health care professional that has executed a provider agreement with Maryland Medicaid.
(25)
“Participant” means an individual who is certified as eligible for, and is receiving, Medical Assistance benefits.
(26)
“Preauthorization” means an approval required from the Department or its designee before the provision of dental or oral health care services.
(27)
“Primary dental office” means the fixed and permanent location where the mobile dental unit:
(a)
Is linked through either ownership or a legally binding contract; and
(b)
Transmits participant records.
(28)
“Program” means the Maryland Medical Assistance Program.
(29)
“Provider” means:
(a)
An individual dentist, duly licensed to provide services for participants, or an association, partnership, or an incorporated or unincorporated group of dentists so licensed, that, through appropriate agreement with the Department, has been identified as a Program provider by the issuance of an individual account number; or
(b)
An approved dental school whose students are permitted under Health Occupations Article, §4-301(b)(1), Annotated Code of Maryland, to treat dental patients and which, through appropriate agreement with the Department, has been identified as a Program provider by issuance of an individual account number.
(30)
“Referral” means a transfer of the patient from a physician or dentist to a dentist for diagnosis and treatment of the condition for which the referral was made. The dentist to whom the referral is made will no longer be considered the consultant.
(31)
“REM” means the fee-for-service managed care program for individuals who have certain rare and expensive health care conditions set forth in COMAR 10.09.69.
(32)
“Self-ligating braces” means braces which utilize a permanently installed, moveable component to secure the archwire without the use of ligatures.
(33)
“Traditional comprehensive orthodontic treatment” means a coordinated diagnosis and treatment to improve craniofacial dysfunction or dentofacial deformity which may utilize fixed and removable orthodontic appliances and focus on specific objectives at various stages of dentofacial development.
Regulation .02 License Requirements.LinkCopy Citation
A.
The provider shall meet all license requirements as set forth in COMAR 10.09.36.02.
B.
A dentist shall be licensed and legally authorized to practice dentistry in the state in which service is provided.
C.
All dentists and dental hygienists working for a mobile dental unit or mobile dental practice shall be currently licensed and registered with the Maryland Board of Dental Examiners.
D.
The driver of the mobile dental unit:
(1)
Shall possess a valid operator’s license appropriate for the type of vehicle that is driven;
(2)
May not have violations related to the operation of a motor vehicle in the last 3 years; and
(3)
May not have any violations involving alcohol or other illegal substances related to the operation of a motor vehicle in the last 10 years.
E.
An EPSDT certified provider shall be:
(1)
A doctor of medicine licensed and legally authorized to practice in the state in which the service is provided;
(2)
A nurse practitioner who is licensed and certified to practice in the state in which services are provided;
(3)
A physician assistant who is licensed to practice in the state in which services are provided; or
(4)
A local health department, or a federally qualified health center, which has on its staff, and under whose supervision EPSDT services are delivered:
(a)
A doctor of medicine licensed in the state in which the service is provided;
(b)
A nurse practitioner licensed and certified in the state in which services are provided; or
(c)
A physician assistant licensed in the state in which services are provided.
F.
The provider shall ensure that all X-ray or other radiological equipment is inspected and meets the standards established in COMAR 26.12.01 or other applicable standards established by the state in which the service is provided.
G.
The provider shall ensure that Clinical Laboratory Improvement Amendments (CLIA) certification exists for all clinical laboratory services rendered, and:
(1)
If located in Maryland, comply with requirements of Health-General Article, Title 17, Subtitles 2 and 3, Annotated Code of Maryland, and COMAR 10.10.06; or
(2)
If located out-of-State, comply with other applicable standards established by the state or locality in which the service is provided.
Regulation .03 Provider Qualifications and Conditions for Participation.LinkCopy Citation
A.
General requirements for participation in the Program are that a provider shall:
(1)
Comply with requirements set forth in COMAR 10.09.36; and
(2)
If delivering services via telehealth, comply with COMAR 10.09.49 and any subregulatory guidance issued by the Department.
B.
To participate in the Program as a dental provider, a provider shall meet the licensure requirements established in Regulation .02 of this chapter.
C.
To participate in the Program as an EPSDT certified provider of fluoride varnish services, the provider shall:
(1)
Have MDH Certification for the Application of Fluoride Varnish; and
(2)
Meet the following requirements:
(a)
Be board-certified in one of the following:
(i)
Pediatrics;
(ii)
Family practice; or
(iii)
Internal medicine;
(b)
Be a licensed physician, physician assistant, or licensed and certified nurse practitioner, delivering primary health care to children and adolescents; or
(c)
Be a local health department or a federally qualified health center.
D.
The provider shall:
(1)
Complete the Dental Provider Application; and
(2)
Submit verification of the National Provider Identifier (NPI) Number.
E.
Mobile Dental Unit and Mobile Dental Practice.
(1)
The mobile dental unit shall provide or arrange for comprehensive dental services with a participating Maryland Healthy Smiles Dental Program provider.
(2)
The mobile dental unit and mobile dental practice shall be linked through either ownership or a legally binding contract to a brick and mortar dental office that has a permanent and fixed location.
(3)
The brick and mortar dental office shall participate in the Maryland Healthy Smiles Dental Program.
(4)
The mobile dental unit and mobile dental practice shall have and utilize the electronic technology that enables the same day exchange of patient records with:
(a)
The brick and mortar dental office; and
(b)
If requested, the dental office of the parent or legal guardian's choice.
(5)
The mobile dental unit and mobile dental practice service area shall be limited to 30 miles in a rural setting and 10 miles in an urban setting from the brick and mortar dental office that the mobile dental unit and mobile dental practice is either owned by or with which the dental office holds a legally binding contract.
(6)
A mobile dental unit and mobile dental practice shall:
(a)
Maintain dental records for the patient;
(b)
Observe all patient rights;
(c)
Obtain written, informed consent from a parent or legal guardian, which shall:
(i)
Be renewed each school year before treating a minor; and
(ii)
Allow the parent or legal guardian to request that the dental records be sent to a provider of their choice;
(d)
Comply with all applicable federal, State, and local laws, regulations, and ordinances regulating:
(i)
Equipment;
(ii)
Flammability;
(iii)
Construction;
(iv)
Infection control;
(v)
Sanitation procedures; and
(vi)
Zoning;
(e)
Comply with the statutes and regulations of the Maryland Department of the Environment for all dental radiographic and imaging equipment;
(f)
Obtain, keep current, and make readily available all applicable county and city licenses or permits necessary to operate the mobile dental unit or mobile dental practice which would include the active dentist, hygienist and dental assistant licenses and the dental radiographic and imaging equipment permits;
(g)
Provide an update to the Department regarding any mobile dental unit or mobile dental practice provider changes within 72 hours;
(h)
Provide access to a ramp or a lift if services are provided to disabled individuals;
(i)
Have ready access to a properly functioning sterilization system;
(j)
Have ready access to an adequate supply of potable water, including hot water;
(k)
Have immediate access to toilet facilities;
(l)
Have an appropriately covered noncorrosive metal container for refuse and waste materials;
(m)
Have carbon monoxide and smoke detection devices or systems installed and in proper working condition;
(n)
Have a chair designed and purposed exclusively for the provision of dental services;
(o)
Have a dental treatment light;
(p)
Have a radiograph unit with appropriate processing equipment;
(q)
Have an evacuation unit suitable for dental surgical use;
(r)
Have written procedures for medical emergencies;
(s)
Have appropriate equipment to treat medical emergencies;
(t)
Have appropriate and sufficient dental instruments and infection control supplies; and
(u)
Have any other equipment or system that is necessary to provide the services being rendered by the mobile dental unit or mobile dental practice.
(7)
Dental hygienists or dental assistants may not solely operate a mobile dental unit or mobile dental practice.
(8)
The owner or owners of a mobile dental unit or mobile dental practice shall submit a business plan to the dental administrative service organization for the mobile unit or mobile dental practice that includes:
(a)
The mission of the mobile dental unit and mobile dental practice;
(b)
Verification of ownership of the mobile dental unit and mobile dental practice;
(c)
A list of the clinical practitioners that will render services in the mobile dental unit or mobile dental practice; and
(d)
The targeted population.
Regulation .04 Covered Services.LinkCopy Citation
A.
The Program covers medically necessary dental services for participants younger than 21 years old and eligible former foster care participants younger than 26 years old, including but not limited to the following:
(1)
Emergency, preventive, diagnostic, and treatment services;
(2)
Semiannual cleaning, fluoride treatment and examination;
(3)
Pit and fissure sealants for the occlusal surfaces of posterior permanent teeth that are without decay;
(4)
Orthodontic care for conditions which:
(a)
Have adjusted case scores of at least 15 points on the Handicapping Labio-Lingual Deviations Index (HLD) Table No. 4; and
(b)
Cause dysfunction due to a handicapping malocclusion that is supported by comprehensive pretreatment orthodontic records, which include at a minimum:
(i)
Cephalometric head film with analysis;
(ii)
Panoramic or full series periapical radiographs;
(iii)
Extra-oral and intra-oral photographs;
(iv)
Clinical summary with diagnosis;
(v)
HLD score sheets from attending orthodontist; and
(vi)
Treatment plan;
(5)
Consultations for participants who meet the requirements of §A(1), (2), (3), or (4) of this regulation;
(6)
Drugs dispensed or injectable drugs administered by the dentist within the limitations of COMAR 10.09.03;
(7)
Oral Health assessment by an EPSDT certified provider, and if determined medically necessary, the application of fluoride varnish for children 9 months old through 5 years old;
(8)
General anesthesia during dental procedures, when it is medically necessary; and
(9)
Fluoride varnish.
B.
The Program covers the following medically necessary dental services for participants 21 years old or older:
(1)
Periodic, limited, and comprehensive oral examinations;
(2)
X-rays, including:
(a)
First and each additional intraoral periapical film;
(b)
Single, two, three, or four film bitewings, which are limited to:
(i)
Two per patient per year for REM participants 21 years old or older; or
(ii)
One per patient per year for pregnant participants 21 years old or older; and
(c)
One panoramic radiographic image every 36 months;
(3)
Prophylaxis for adults, which is limited to:
(a)
One per patient per 3 months for REM participants 21 years old or older; or
(b)
Two per patient per 12 months for adults ages 21 and over;
(4)
Topical application of fluoride, which is limited to:
(a)
One application per patient per 6 months for REM participants 21 years old or older; or
(b)
One application per patient per year for pregnant and postpartum participants 21 years old or older;
(5)
Amalgam restorations for permanent teeth for one, two, three, four, or more surfaces, which are limited to one identical restoration per tooth per 24 months;
(6)
Resin restorations for anterior permanent teeth for one, two, three, four, or more surfaces or involving incisal angle, which are limited to one identical restoration per tooth per 24 months;
(7)
Other restorative services including:
(a)
Recementing of crowns, which is limited to two times for the same crown;
(b)
Prefabricated stainless steel crown for permanent teeth;
(c)
Fillings — sedative, interim or temporary filling; and
(d)
Pin retention — per tooth, in addition to restoration;
(8)
Pulp capping, direct and indirect, excluding final restoration;
(9)
Gingovectomy or gingivoplasty — per quadrant, which is limited to two quadrants per year per patient;
(10)
Periodontal scaling and root planning — per quadrant;
(11)
Full mouth debridement, which is limited to one per patient per 2 years, and may not be completed on the same day as prophylaxis;
(12)
Periodontal maintenance — following active periodontal therapy, which is limited to two per patient per year;
(13)
Adjustment of complete maxillary and mandibular denture;
(14)
Adjustment of partial maxillary and mandibular denture;
(15)
Recementing of bridge, which is limited to two times for the same bridge;
(16)
Extractions of:
(a)
Coronal remnants for deciduous teeth; and
(b)
Erupted tooth or exposed root;
(17)
Biopsy of oral tissue, hard or soft;
(18)
Alveoplasty, in conjunction or not in conjunction with extractions — per quadrant;
(19)
Incision and drainage of abscess intraoral; and
(20)
Palliative emergency treatment of dental pain that is not associated with recently rendered service.
C.
The Program shall reimburse for covered services in §§A and B of this regulation if:
(1)
The services are rendered in:
(a)
The dentist's office;
(b)
The participant's home by an approved mobile dental unit;
(c)
A general acute hospital;
(d)
A skilled or intermediate care nursing facility;
(e)
A free-standing clinic;
(f)
An EPSDT certified provider's office;
(g)
An approved mobile dental unit or mobile dental practice;
(h)
A Medicare-certified ambulatory surgical center; or
(i)
Via telehealth in compliance with COMAR 10.09.49.
(2)
The services are provided by the dentist or one of the following:
(a)
Another licensed dentist enrolled with Medicaid in the dentist’s employ;
(b)
A dental hygienist or dental assistant, provided that the individual rendering the service is:
(i)
In the dentist's employ or in the employ of a public health program;
(ii)
Under general supervision of a licensed dentist; and
(iii)
Within the scope of the individual’s training or certification for the purpose of assisting in the provision of dental services; or
(c)
An EPSDT certified provider for the purpose of applying fluoride varnish;
(3)
The services are clearly related to the participant's individual dental care needs as ameliorative, diagnostic, curative, palliative, preventive, or rehabilitative services; and
(4)
The services are adequately described on the participant's dental care record in accordance with record-keeping practices detailed in COMAR 10.44.30.
Regulation .05 Limitations.LinkCopy Citation
A.
The Program places the following limitations upon covered services:
(1)
Reimbursement for a complete radiographic survey or full series of X-rays of the mouth may not be made more frequently than once every 3 years to the same provider, or in the case of a group practice, to any partner or associate of that practice, unless medically necessary or specifically required or requested by the Program.
(2)
For any traumatic injury case, a provider may be reimbursed for a maximum of four panoramic or other extra-oral radiographs. When services are rendered by members of a group practice or association, reimbursement to the group practice or association shall also be limited to a maximum of four panoramic or other extra-oral radiographs.
(3)
Endodontic therapies and pulpectomies may not be covered when:
(a)
Root resorption has started and exfoliation is imminent;
(b)
Gross periapical or periodontal pathosis is demonstrated on the radiograph; or
(c)
The general oral condition does not justify endodontic therapy.
(4)
Reimbursement for crowns will be limited to permanent resin fused to metal crowns, permanent porcelain fused to metal crowns, permanent nonprecious metal (full cast), provisional resin crowns, prefabricated zirconia crowns, and stainless steel crowns.
(5)
Composite restorations will be covered for all teeth when necessary for the particular conditions of the patient.
(6)
Replacement dentures for participants who meet the requirements of Regulation .04A(3) of this chapter will be covered only when:
(a)
Dentures have been lost, broken, or stolen after 1 year of placement; or
(b)
Adjustment, repair, relining, or rebasing of the patient's present denture does not make it serviceable.
(7)
Rebasing is included in the 6 months of aftercare following denture placement, and may not be provided more frequently than once every 2 years after that.
(8)
Reimbursement for endodontic therapy includes all diagnostic tests, preoperative and postoperative radiographs, preoperative and postoperative treatments, pulpotomies and pulpectomies.
(9)
Reimbursement for a sinus closure will only be made when this service is rendered as a separate procedure and not in conjunction with the removal of a tooth.
(10)
Separate reimbursement will not be made for cavity liners and office visits, as these procedures are considered to be components of the necessary treatment. These services may not be billed to the participant.
(11)
The provider may bill for emergency treatment or for the actual dental procedures rendered during an emergency visit, but not for both.
(12)
Gold restorations, gold crowns, and gold replacement appliances are not covered services.
(13)
The Program's fee for a complete series of intra-oral radiographs including bitewings, represents the maximum payable for any combination of periapical X-rays and bitewings.
(14)
Assistant surgeons' services are covered only:
(a)
As specified in Regulation .07M of this chapter;
(b)
If the procedures were rendered in a hospital or a Medicare-certified ambulatory surgery center; and
(c)
If the assistant surgeon is a dentist.
B.
The Program does not cover:
(1)
Fixed bridge work;
(2)
Cosmetic procedures;
(3)
Inpatient hospital dental or oral health care services rendered during an admission;
(4)
Services which are investigational or experimental;
(5)
Local anesthesia as a separate charge;
(6)
Duplication of dentures;
(7)
Drugs and supplies dispensed by the dentist which are acquired by the dentist at no cost;
(8)
Referrals;
(9)
Diagnostic models as a separate charge;
(10)
Office visits as a separate service;
(11)
Immediate dentures;
(12)
Consultant payments when a member of the house staff of a hospital either requests or provides the consultations or, in the case of a group practice, to any partner or associate of that practice who either requests or provides the consultation;
(13)
Aftercare services as a separate charge to a provider or, in the case of a group practice, to any partner or associate of that practice;
(14)
Services when reimbursement is included under another segment of the Program;
(15)
Unilateral partial dentures replacing fewer than three teeth, excluding third molars;
(16)
Implants;
(17)
More than one, per participant per lifetime, of the following services:
(a)
Traditional comprehensive orthodontic treatment; or
(b)
Self-ligating braces; and
(18)
Services rendered without the required preauthorization.
Regulation .06 Preauthorization Requirements.LinkCopy Citation
A.
Preauthorization is issued when:
(1)
Program procedures are met;
(2)
Program limitations are met;
(3)
The provider submits to the Department, adequate documentation demonstrating that the service to be preauthorized is medically necessary; and
(4)
The participant is eligible for the service.
B.
Preauthorization is required for the following:
(1)
Resin fused to metal crown;
(2)
Porcelain fused to metal crown;
(3)
Nonprecious metal crown (full cast);
(4)
Apicoectomies and periradicular services;
(5)
Certain periodontal services;
(6)
Complete upper/lower denture;
(7)
Partial upper/lower denture (including clasps and teeth);
(8)
Any elective clinical or surgical procedure not listed on the current dental fee schedule;
(9)
Surgery normally considered cosmetic but qualified by traumatic or pathological causation;
(10)
Laboratory rebasing of dentures;
(11)
Addition of teeth or clasps to an existing, functional complete or partial denture;
(12)
General restorative treatment to be rendered in a hospital;
(13)
Special periodontal appliances;
(14)
Apexification and recalcification procedures;
(15)
Hemisection, including any root removal, including endodontic therapy;
(16)
Overdenture complete;
(17)
Overdenture partial;
(18)
Condylectomy;
(19)
Meniscectomy;
(20)
Arthrotomy; and
(21)
All orthodontic procedures.
C.
At a minimum, the documentation required when requesting preauthorization for the following services is:
(1)
A complete radiographic survey of the mouth for:
(a)
Complete or partial dentures; or
(b)
Except in the case of special needs children, where sedation would be required for a complete radiograph of the mouth, special periodontal appliances and periodontal therapies;
(2)
Individual periapical radiographs for:
(a)
Except in the case of special needs children, where sedation would be required for an individual periapical radiograph or bitewing, endodontic therapy (periapicals and bitewings shall be submitted when the request is for posterior teeth);
(b)
Apicoectomy;
(c)
Except in the case of special needs children, where sedation would be required for an individual periapical radiograph, periradicular and apexification or recalcification services; and
(d)
Full coverage permanent crown restorations (excludes stainless steel and provisional resin crowns); and
(3)
Full mouth radiographs and a periodontal chart, identifying the depths and locations of the pockets, when periodontal services are requested.
D.
Except as described in §F of this regulation, preauthorization is valid for dental services when the services are approved and completed within 6 months after the date of the receipt of the preauthorization number from the Program.
E.
Preauthorization normally required by the Program is waived when the services are covered and approved by Medicare. However, if the entire or any part of a claim is rejected by Medicare, and the claim is referred to the Program for payment, payment will be made for services covered by the Program only if authorization for those services has been obtained before billing. Non-Medicare claims require preauthorization according to §§A—D of this regulation.
F.
Preauthorization for Orthodontic Treatment.
(1)
Preauthorization is required for traditional comprehensive orthodontic treatment and for self-ligating braces for the correction of medically necessary conditions, which cause dysfunction due to a handicapping malocclusion. At a minimum the following comprehensive pretreatment documentation shall be submitted:
(a)
Cephalometric head film with analysis;
(b)
Panoramic or full series of periapical radiographs;
(c)
68 diagnostic quality extra-oral and intra-oral photographs;
(d)
Clinical summary with diagnosis;
(e)
HLD score sheets from attending orthodontist; and
(f)
Treatment plan.
(2)
Preauthorization for periodic orthodontic treatment is valid for:
(a)
24 months for traditional comprehensive orthodontic treatment; or
(b)
12 months for self-ligating braces.
Regulation .07 Payment Procedures.LinkCopy Citation
A.
To obtain compensation from the Department for covered services, the provider shall submit a request for payment on the form designated by the Department with the following data or attachments:
(1)
If applicable, the preauthorization number shall be inserted in the designated appropriate field on the invoice claim form;
(2)
If applicable, pathology reports shall be attached to the claim form; and
(3)
If applicable, comprehensive narratives shall be attached to the claim form for those services that are “By Report”.
B.
The Department reserves the right to return to the provider, before payment, all invoices not properly signed or completed.
C.
All prosthetic appliances shall be inserted in the mouth and adjusted before the Program is billed, except when the patient has expired, cannot be located, or refuses to return for completion of treatment. In these cases, the Department will reimburse the provider 80 percent of the maximum State fee for the procedure code for the laboratory bill only.
D.
The provider shall charge the Program the provider's customary charge to the general public for similar services. If the service is free to individuals not covered by Medicaid:
(1)
The provider:
(a)
May charge the Program; and
(b)
Shall be reimbursed in accordance with §E of this regulation; and
E.
The current Maryland Medicaid Dental Services Fee Schedule and Procedure Codes CDT is incorporated by reference, effective January 1, 2024.
F.
The provider shall be paid the lesser of:
(1)
The provider's customary charge to the general public unless the service is free to individuals not covered by Medicaid; or
(2)
The rate in accordance with the Department's fee schedule.
G.
The provider may not bill the Department or the participant for:
(1)
Completion of forms and reports;
(2)
Broken or missed appointments;
(3)
Professional services rendered by mail or telephone; or
(4)
Providing a copy of a participant's medical record when requested by another licensed provider on the participant's behalf.
H.
Reimbursement for Traditional Comprehensive Orthodontic Treatment.
(1)
The Program shall reimburse for orthodontic treatment for a maximum of 24 periodic visits at an established rate, provided the treatment meets the standards established in COMAR 10.09.05.06F.
(2)
Orthodontic treatment is a once in a lifetime benefit.
I.
Reimbursement for Self-Ligating Braces.
(1)
The Program shall reimburse for:
(a)
A pre-orthodontic visit;
(b)
Comprehensive orthodontia; and
(c)
A maximum of 12 periodic treatment visits at an established rate, provided the treatment meets the standards established in COMAR 10.09.05.06F.
(2)
When a claim is submitted to the Program for the banding of self-ligating braces, the following documentation shall be submitted with the claim:
(a)
A photograph of the recipient's oral cavity to confirm the placement of self-ligating braces; and
(b)
A statement signed by the parent or guardian of the child receiving treatment, acknowledging that:
(i)
Orthodontic services are a once in a lifetime benefit; and
(ii)
The participant will not be able to pursue additional orthodontic services from the Medicaid Program at a later date.
J.
The Department may not make direct payment to nurses, dental assistants, anesthetists, or dental hygienists.
K.
The Department may not make direct payment to the participant.
L.
Billing time limitations for claims submitted pursuant to this chapter are set forth in COMAR 10.09.36.06.
M.
Those dental clinics licensed as part of a hospital in Maryland may charge and be reimbursed according to rates approved by the Health Services Cost Review Commission (HSCRC) pursuant to COMAR 10.37.03.
N.
Payment for assistant surgeons' services is a maximum of 20 percent of the listed fee paid to the primary surgeon or the fee as determined by the Program for the treatment rendered. The minimum allowance is $25 or the dentist's charge, whichever is lower.
Regulation .08 Recovery and Reimbursement.LinkCopy Citation
A.
If the participant has insurance or other coverage, or if any other person is obligated, either legally or contractually, to pay for or to reimburse the participant for services covered by this chapter, the provider shall seek payment from that source first. If an insurance carrier rejects the claim or pays less than the amount allowed by the Medical Assistance Program, the provider may submit a claim to the Program. The provider shall submit a copy of the insurance carrier's notice or remittance advice with his invoice. If payment is made by both the Program and the insurance or other source for the same service, the provider shall refund to the Department, within 60 days of receipt, the amount paid by the Program, or the insurance or other source, whichever is less.
B.
The provider shall reimburse the Department for any overpayment.
Regulation .09 Cause for Suspension or Removal and Imposition of Sanctions.LinkCopy Citation
A.
If the Department determines that a provider, dentist, any agent or employee of the provider, or any person with an ownership interest in the provider has failed to comply with applicable federal or State laws or regulations, the Department may initiate one or more of the following actions against the responsible party:
(1)
Suspension from the Program;
(2)
Withholding of payment by the Department;
(3)
Removal from the Program;
(4)
Disqualification from future participation in the Program, either as a provider or as a person providing services for which Program payment will be claimed.
B.
If the Secretary of Health and Human Services suspends or removes a provider from participation in Medicare, the Department will take similar action.
C.
The Department shall give to the provider reasonable written notice of its intention to impose sanctions. In the notice, the Department will establish the effective date and the reasons for the proposed action, and advise the provider of the right to appeal.
D.
Any provider who voluntarily withdraws from the Program or is removed or suspended from the Program according to this regulation shall notify participants that the provider no longer honors Medical Assistance cards before rendering additional services.
Regulation .10 Appeal Procedures.LinkCopy Citation
A.
Providers may exercise appeal rights pursuant to State Government Article, Title 10, Subtitle 2, Annotated Code of Maryland.
B.
The provider may appeal a decision to the Office of Administrative Hearings as specified in COMAR 10.09.36.09.
Regulation .11 Interpretive Regulation.LinkCopy Citation
Except when the language of a specific regulation indicates an attempt by the Department to provide reimbursement for covered services to Program participants without regard to the availability of federal financial participation, State regulations shall be interpreted in conformity with applicable federal statutes and regulations.
Chapter annotations
Authority: Health-General Article, §§2-104(b), 15-103, and 15-105, Annotated Code of Maryland
History: Effective date: January 1, 1976 (2:29 Md. R. 1740)
History: Regulations .01—.10 amended effective October 13, 1976 (3:21 Md. R. 1206)
History: Regulations .01I, .04A, .05, and .06B amended as an emergency provision effective February 1, 1982 (9:2 Md. R. 110); emergency status extended at 9:11 Md. R. 1122 and 9:17 Md. R. 1697 (Emergency provisions are temporary and are not printed in COMAR)
History: Regulation .06C adopted effective April 4, 1980 (7:7 Md. R. 708)
History: Regulation .07D amended as an emergency provision effective July 1, 1982 (9:13 Md. R. 1347); adopted permanently effective November 1, 1982 (9:21 Md. R. 2106)
History: Regulation .07F amended as an emergency provision effective February 1, 1979 (6:2 Md. R. 71); emergency status extended to June 1, 1979 (6:12 Md. R. 1045); adopted permanently effective June 1, 1979 (6:11 Md. R. 979)
History: Regulation .07L amended as an emergency provision effective July 1, 1978 (5:14 Md. R. 1131); adopted permanently effective November 3, 1978 (5:22 Md. R. 1673)
History: Regulation .11 adopted effective October 25, 1982 (9:21 Md. R. 2106)
History: Chapter revised effective January 1, 1983 (9:25 Md. R. 2480)
History: Regulations .01, .04, and .05 amended as an emergency provision effective December 2, 1992 (19:26 Md. R. 2282); amended permanently effective June 1, 1993 (20:10 Md. R. 851)
History: Regulation .01B amended effective October 1, 1985 (12:19 Md. R. 1848); August 27, 2007 (34:17 Md. R. 1507); May 19, 2008 (35:10 Md. R. 972)
History: Regulation .01B amended as an emergency provision effective July 16, 2009 (36:17 Md. R. 1310); amended permanently effective November 30, 2009 (36:24 Md. R. 1858)
History: Regulation .01B amended effective December 27, 2010 (37:26 Md. R. 1787); March 30, 2015 (42:6 Md. R. 511); March 14, 2016 (43:5 Md. R. 385); August 14, 2017 (44:16 Md. R. 808); May 20, 2019 (46:10 Md. R. 485); November 15, 2021 (48:23 Md. R. 979); July 10, 2023 (50:13 Md. R. 512); October 13, 2025 (52:20 Md. R. 1001)
History: Regulation .02 amended as an emergency provision effective September 16, 1992 (19:20 Md. R. 1812); amended permanently effective January 1, 1993 (19:25 Md. R. 2205)
History: Regulation .02 amended as an emergency provision effective July 16, 2009 (36:17 Md. R. 1310); amended permanently effective November 30, 2009 (36:24 Md. R. 1858)
History: Regulation .02 amended effective December 27, 2010 (37:26 Md. R. 1787)
History: Regulation .02C amended effective October 13, 2025 (52:20 Md. R. 1001)
History: Regulation .02D amended effective May 19, 2008 (35:10 Md. R. 972)
History: Regulation .02E amended effective May 20, 2019 (46:10 Md. R. 485)
History: Regulation .02F amended effective August 14, 2017 (44:16 Md. R. 808)
History: Regulation .03 amended as an emergency provision effective September 16, 1992 (19:20 Md. R. 1812); amended permanently effective January 1, 1993 (19:25 Md. R. 2205)
History: Regulation .03 amended as an emergency provision effective July 16, 2009 (36:17 Md. R. 1310); amended permanently effective November 30, 2009 (36:24 Md. R. 1858)
History: Regulation .03 amended effective May 20, 2019 (46:10 Md. R. 485); July 10, 2023 (50:13 Md. R. 512)
History: Regulation .03B amended effective May 19, 2008 (35:10 Md. R. 972)
History: Regulation .03E amended effective November 15, 2021 (48:23 Md. R. 979); October 13, 2025 (52:20 Md. R. 1001)
History: Regulation .03F adopted effective December 27, 2010 (37:26 Md. R. 1787)
History: Regulation .03F amended effective March 14, 2016 (43:5 Md. R. 385); August 14, 2017 (44:16 Md. R. 808)
History: Regulation .03K adopted effective January 30, 1984 (11:2 Md. R. 113)
History: Regulation .04 amended effective May 19, 2008 (35:10 Md. R. 972)
History: Regulation .04 amended as an emergency provision effective July 16, 2009 (36:17 Md. R. 1310); amended permanently effective November 30, 2009 (36:24 Md. R. 1858)
History: Regulation .04 amended effective August 14, 2017 (44:16 Md. R. 808); May 20, 2019 (46:10 Md. R. 485); November 15, 2021 (48:23 Md. R. 979); July 10, 2023 (50:13 Md. R. 512)
History: Regulations .04A, .05A, and .07E amended, and .07N adopted as an emergency provision effective February 1, 1989 (16:3 Md. R. 336); adopted permanently effective June 1, 1989 (16:10 Md. R. 1108)
History: Regulation .04B amended effective October 13, 2025 (52:20 Md. R. 1001)
History: Regulation .04C amended effective December 27, 2010 (37:26 Md. R. 1787); March 30, 2015 (42:6 Md. R. 511)
History: Regulation .05 amended effective October 1, 1985(12:19 Md. R. 1848); May 19, 2008 (35:10 Md. R. 972)
History: Regulation .05 amended as an emergency provision effective July 16, 2009 (36:17 Md. R. 1310); amended permanently effective November 30, 2009 (36:24 Md. R. 1858)
History: Regulation .05 amended effective May 20, 2019 (46:10 Md. R. 485); October 13, 2025 (52:20 Md. R. 1001)
History: Regulation .05A amended effective August 14, 2017 (44:16 Md. R. 808)
History: Regulation .05B amended effective November 15, 2021 (48:23 Md. R. 979)
History: Regulation .05C repealed effective July 10, 2023 (50:13 Md. R. 512)
History: Regulation .06 amended effective May 19, 2008 (35:10 Md. R. 972)
History: Regulation .06 amended as an emergency provision effective July 16, 2009 (36:17 Md. R. 1310); amended permanently effective November 30, 2009 (36:24 Md. R. 1858)
History: Regulation .06 amended effective November 15, 2021 (48:23 Md. R. 979)
History: Regulation .06A amended effective August 27, 2007 (34:17 Md. R. 1507)
History: Regulation .06B amended effective October 1, 1985 (12:19 Md. R. 1848); December 24, 1990 (17:25 Md. R. 2907); July 10, 2023 (50:13 Md. R. 512)
History: Regulation .06D amended effective August 14, 2017 (44:16 Md. R. 808)
History: Regulation .06F amended effective December 27, 2010 (37:26 Md. R. 1787); March 14, 2016 (43:5 Md. R. 385)
History: Regulation .07 amended effective October 1, 1985 (12:19 Md. R. 1848)
History: Regulation .07 amended as an emergency provision effective April 9, 1991 (18:9 Md. R. 1005); amended permanently effective October 7, 1991 (18:18 Md. R. 2004)
History: Regulation .07 amended as an emergency provision effective July 1, 1992 (19:15 Md. R. 1381); amended permanently effective November 1, 1992 (19:21 Md. R. 1890)
History: Regulation .07 amended effective May 19, 2008 (35:10 Md. R. 972)
History: Regulation .07 amended as an emergency provision effective July 16, 2009 (36:17 Md. R. 1310); amended permanently effective November 30, 2009 (36:24 Md. R. 1858)
History: Regulation .07 amended effective December 27, 2010 (37:26 Md. R. 1787); May 20, 2019 (46:10 Md. R. 485); July 10, 2023 (50:13 Md. R. 512)
History: Regulation .07D, F, G amended effective July 4, 2016 (43:13 Md. R. 712)
History: Regulation .07E amended as an emergency provision effective July 1, 1984 (11:13 Md. R. 1170); adopted permanently effective October 29, 1984 (11:21 Md. R. 1811)
History: Regulation .07E amended as an emergency provision effective October 1, 1986 (13:22 Md. R. 2393); adopted permanently effective February 9, 1987 (14:2 Md. R. 129)
History: Regulation .07E amended effective April 20, 1998 (25:8 Md. R. 596)
History: Regulation .07E amended as an emergency provision effective July 1, 2000 (27:15 Md. R. 1396); amended permanently effective October 30, 2000 (27:21 Md. R. 1976)
History: Regulation .07E amended as an emergency provision effective October 1, 2001 (28:23 Md. R. 2052); adopted permanently effective January 21, 2002 (29:1 Md. R. 23)
History: Regulation .07E amended as an emergency provision effective March 25, 2004 (31:8 Md. R. 643); amended permanently effective June 21, 2004 (31:12 Md. R. 911)
History: Regulation .07E amended effective August 15, 2005 (32:16 Md. R. 1392); August 27, 2007 (34:17 Md. R. 1508); March 30, 2015 (42:6 Md. R. 511); October 13, 2025 (52:20 Md. R. 1001)
History: Regulation .07E, G amended effective August 27, 2018 (45:17 Md. R. 803)
History: Regulation .07E, I amended effective November 15, 2021 (48:23 Md. R. 979)
History: Regulation .07E, I, K amended effective August 14, 2017 (44:16 Md. R. 808)
History: Regulation .07L amended effective January 30, 1984 (11:2 Md. R. 113); September 10, 1984 (11:18 Md. R. 1584)
History: Regulation .07L amended as an emergency provision effective January 28, 1991 (18:3 Md. R. 301); emergency status expired April 8, 1991 (18:9 Md. R. 1004)
History: Regulation .08 amended as an emergency provision effective April 9, 1991 (18:9 Md. R. 1005); amended permanently effective October 7, 1991 (18:18 Md. R. 2004)
History: Regulation .08 amended as an emergency provision effective July 1, 1992 (19:15 Md. R. 1381); amended permanently effective November 1, 1992 (19:21 Md. R. 1890)
History: Regulation .08A amended effective May 12, 1986 (13:9 Md. R. 1029); August 14, 2017 (44:16 Md. R. 808)
History: Regulation .09 amended as an emergency provision effective July 16, 2009 (36:17 Md. R. 1310); amended permanently effective November 30, 2009 (36:24 Md. R. 1858)
History: Regulation .09D amended effective August 14, 2017 (44:16 Md. R. 808)
History: Regulation .10 amended effective June 6, 1983 (10:11 Md. R. 974)
History: Regulation .10 amended as an emergency provision effective July 16, 2009 (36:17 Md. R. 1310); amended permanently effective November 30, 2009 (36:24 Md. R. 1858)
History: Regulation .10 amended effective October 13, 2025 (52:20 Md. R. 1001)
History: Regulation .11 amended effective August 14, 2017 (44:16 Md. R. 808)