Statutes, codes, and regulations
Maine Administrative Code
Department 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICESDivision 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERALChapter 104 - MAINE STATE SERVICES MANUAL
Section 144-104-6 - Independent Practice Dental Hygienist Services
Subsection 144-104-6.07 - PROVIDER REIMBURSEMENT

C.M.R. 10, 144, ch. 104, § 144-104-6, subsec. 144-104-6.07

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Current through 2024-51, December 18, 2024
Subsection 144-104-6.07 - PROVIDER REIMBURSEMENT
A.IPDH Services Provided in Non-FQHC Settings: will be reimbursed according to the following chart, including any restrictions listed in the chart, so long as the eligibility and other requirements of this regulation are met.
B.IPDH Services Provided in FQHC Settings: will utilize the following chart, including any restrictions listed in the chart, except that FQHCs will not utilize the reimbursement rate that is listed in the Chart. So long as the eligibility and other requirements of this regulation are met, reimbursement for these services is as follows:
1. If the FQHC was reimbursed by MaineCare, on the date of service, for an ambulatory clinic visit for the Member, then the FQHC is not eligible for reimbursement for a Section 6 IPDH service on that date.
2. The reimbursement rate for FQHCs for IPDH services will be that FQHC's MaineCare ambulatory clinic visit rate that was in effect on the date the IPDH service was delivered.

Covered Service

Age/ICF-MR

Proc.

Code

Description

under age 21 & all ICF-IID residents

age 21 & over when allowed under MBM Chap II, Sec 25.04

Additional Limits

Max Allow for IPDH services in non-FQHC settings

D0210

Intraoral - Complete Series of Radiographic Images

YES

YES

Must include 12 periapical plus 2 posterior bitewings, allowed only once every 3 years, except as part of approved orthodontics.

$43.50

D0220

Intraoral - Periapical, First Radiographic Image

YES

YES

$8.00

D0230

Intraoral - Periapical, Each Additional Radiographic Image

YES

YES

$6.50

D0240

Intraoral - Occlusal Radiographic Image

YES

YES

$10.00

D0250

Extraoral - First Radiographic Image

YES

YES

$9.00

D0260

Extraoral - Each Additional Radiographic Image

YES

YES

$9.00

D0270

Bitewing - Single Radiographic Image

YES

YES

Posterior bitewings alone are once per calendar year.

$8.00

D0272

Bitewings - Two Radiographic Images

YES

YES

Posterior bitewings alone are once per calendar year.

$15.00

D0273

Bitewings - Three Radiographic Images

YES

YES

Posterior bitewings alone are once per calendar year .

$17.50

D0274

Bitewings - Four Radiographic Images

YES

YES

Posterior bitewings alone are once per calendar year.

$20.00

D0277

Vertical Bitewings - 7-8 Radiographic Images

YES

YES

$30.00

D0330

Panoramic Radiographic Image

YES

YES

Reimbursable: (1) for interceptive orthodontics; (2) for oral surgery; (3) once per five (5) years when used in conjunction with any Preventative Service or Diagnostic Service (as defined in MaineCare Benefits Manual Ch. III Sec 25). .

$43.00

D1110

Prophylaxis - Adult

YES

YES

Limited to age 13 and over. Twice per calendar year, but no more than once every 150 days. Includes oral hygiene instruction. IPDHs may use this code only for members up to age 21.

$40.00

D1120

Prophylaxis - Child

YES

NO

Twice per calendar year, but no more than once every six months requires 150 days. Includes oral hygiene instruction.

$30.00

D1206

Topical Application of Fluoride Varnish

YES

NO

For members under age 3, twice per calendar year. For members age 3 through age 20, twice per calendar year but no more than once every 150 days. Third per calendar year for all members through age 20 permitted if high caries rate or new restorations within 18 months as documented in record.

$12.00

D1208

Topical Application of Fluoride

YES

NO

For members under age 3, twice per calendar year. For members age 3 through age 20, twice per calendar year but no more than once every 150 days. Third per calendar year for all members through age 20 permitted if high caries rate or new restorations within 18 months as documented in record.

$12.00

D1330

Oral Hygiene Instructions

YES

NO

Three times per calendar year. Not billable the same day as prophylaxis.

$13.00

D1351

Sealant - Per Tooth

YES

NO

Permanent teeth: once every three calendar years per tooth. Primary teeth: once per lifetime of tooth unless documented good cause.

$16.00

D2940

Protective Restoration

YES

YES

Not covered with Pulpotomy.

$30.00

C.M.R. 10, 144, ch. 104, § 144-104-6, subsec. 144-104-6.07