MassHealth BOH reverses Dentaquest Denial

Favorable BOH decision reversing Dentaquest denial of prior authorization for deep gum and root cleaning. Dentaquest is the third party administrator of the MassHealth dental program. The decision concerns periodontal care for an adult.  Note that on the last page the hearing officer writes: “The standards utilized by Dentaquest in its determination of whether there is active periodontal disease appear to be more restrictive than that contemplated under the regulations.” Congratulations to Rita Cheresnowsky at GBLS!

Dentaquest was relying on its subregulatory Office Reference Manual (ORM) the latest version of which is posted here: ORM 7/6/2020 https://www.masshealth-dental.net/MassHealth/media/Docs/MassHealth-ORM.pdf