DENTAL SERVICE OF MASSACHUSETTS, · PDF file140501 MA SWH MDCR 1 Current Dental Terminology © 2014 American Dental Association. All rights reserved. DENTAL SERVICE OF MASSACHUSETTS,

140501 MA SWH MDCR 1

Current Dental Terminology © 2014 American Dental Association. All rights reserved.

DENTAL SERVICE OF MASSACHUSETTS, INC.

DENTAL PROVIDER SERVICE AGREEMENT

THIS AGREEMENT, effective as of the date executed by DSM/DentaQuest (“Effective Date”), is made

between DENTAL SERVICE OF MASSACHUSETTS, Inc. (hereinafter referred to as "DSM/DentaQuest") and

______________________________________________________________ (hereinafter referred to as "Provider").

(Business Entity Name as on W-9)

WHEREAS: DSM/DentaQuest is a company that arranges for the delivery of dental services to eligible

Members of prepaid healthcare plans and employer groups contracting with

DSM/DentaQuest; and

WHEREAS: DSM/DentaQuest has subcontracted with DentaQuest, LLC (“DentaQuest”) for DentaQuest

to provide certain dental administrative services and assistance in establishing a dental

network in Massachusetts

WHEREAS: Provider has an unrestricted license to practice dentistry in the State of Massachusetts and

desires to provide dental services pursuant to the terms and conditions of this Agreement;

NOW, THEREFORE, in consideration of the above and the promises hereinafter contained, the Provider (s) and

DSM/DentaQuest hereby agree as follows:

1. Definitions

1.1 “Agreement” means this Agreement between DSM/DentaQuest and Provider, including all

attachments hereto.

1.2 “Certificate of Coverage” shall mean the document issued by the Plan to a Member, which

outlines the benefits available to Member.

1.3 “Complete Claim” shall mean Provider’s request for Payment, in either written or electronic

format, for providing Covered Services to Member, which satisfies all requirements and procedures

established by DSM/DentaQuest for reimbursement as described in the DSM/DentaQuest Provider

Manual and requires no further information, documentation, adjustment or alteration by Provider to

be adjudicated by DSM/DentaQuest.

1.4 “Covered Services” shall mean those Medically Necessary services provided to Members, in

accordance with the Plan Certificate of Coverage.

1.5 “DSM/DentaQuest Office Reference Manual” shall mean the handbook prepared by

DSM/DentaQuest and made available to Provider, detailing important guidelines and procedures

applicable to Provider pursuant to this Agreement.

1.6 “Medically Necessary” shall mean Health care services that: (1) are consistent with generally

accepted principles of professional medical practice as determined by whether: (a) the service is the

most appropriate available supply or level of service for the Enrollee in question considering

potential benefits and harms to the individual; (b) is known to be effective, based on scientific

evidence, professional standards and expert opinion, in improving health outcomes; or (c) for

services and interventions not in widespread use, is based on scientific evidence; and (2) are the

least intensive and most cost-effective available."

1.7 “Member” shall mean an individual who is eligible to receive Covered Services pursuant to a

Certificate of Coverage.



1.8 “Participating Provider” shall mean those licensed dental professionals or facilities, including

Provider, who have entered into an agreement with DSM/DentaQuest to provide Covered Serviced

to Member(s) and have been duly credentialed by DSM/DentaQuest.

1.9 “Plan” is an insurer, health maintenance organization or any other entity that is an organized system

which combines the delivery and financing of health care and which provides basic health services

to enrolled members.

1.10 “Provider” means the undersigned health professional or entity that has entered into a written

agreement with DSM/DentaQuest to provide certain health services to Members. Each Provider

shall have his, hers or its own distinct tax identification number.

1.11 “Provider Dentist” means a doctor of dentistry, duly licensed and qualified under the applicable

laws, who practices as a shareholder, partner, or employee of Provider.

1.12 “Utilization Review” means a set of formal techniques designed to monitor the use of, or evaluate

the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures or

settings.

2. Provider Obligations

2.1 Provision of Covered Services – Provider agrees to provide Covered Services to Members pursuant

to their Certificate of Coverage, the terms of this Agreement, the DSM/DentaQuest policies and

procedures described in the DSM/DentaQuest Office Reference Manual, applicable standards of

care and Provider’s training, licensure status and competence. Provider agrees to cooperate with

DSM/DentaQuest in the consideration of any Member complaints regarding Provider’s services.

Provider shall perform services for Members in the same manner and in accordance with the same

standards offered to all Provider’s patients. Provider further agrees not to unlawfully differentiate or

discriminate in the treatment of Members or in the quality of services delivered to Members.

2.2 Standard of Care – Provider agrees to assure that all health care services provided under this

Agreement are: of high quality, efficiently performed and Medically Necessary, provided in a

culturally competent manner, in accordance with professionally recognized standards of care and all

applicable laws, rules and regulations and consistent with applicable precepts of professional ethics.

For purposes of this Agreement culturally competent services are those, which meet the racial,

ethnic, and linguistic needs of the Member. Provider agrees to comply with all applicable federal

and state laws relating to non-discrimination and equal employment opportunity, including the Civil

Rights Act of 1964, regulations issued pursuant to that Act and provision of Executive Order 11246

dated September 26, 1965. Provider agrees to provide physical and program accessibility of dental

services to persons with physical and sensory disabilities pursuant to Section 504 of the

Rehabilitation Act of 1973, as amended (29 U.S.C. 794), all requirements imposed by any

applicable DHFS regulations (45 C.F.R. Part 84) of CMS regulation (42 C.F.R. Parts 417 and 434)

and all guidelines and interpretations issued pursuant thereto. Provider shall assure open

communication with Members regarding medically necessary care and appropriate treatment

alternatives, regardless of benefit coverage limitations.

2.3 Cooperation with Quality Improvement, Utilization Review and Similar Programs – Provider agrees

to cooperate with the utilization management, disease management, case management, complaint

resolution, quality improvement and similar programs established by DSM/DentaQuest from time to

time.

2.4 Policies and Procedures – Provider agrees to comply with any and all policies, rules and regulations

of DSM/DentaQuest as they may exist from time to time including, but not limited to, claims

processing, credentialing, quality or cost containment standards established by DSM/DentaQuest

and Plans. Provider agrees to refer patients that require covered specialty services (oral surgery,



endodontics, prosthetics, and orthodontics) that Provider does not perform, only to dental specialists

designated by DSM/DentaQuest.

2.5 Practitioner Representations and Warranties – Practitioner hereby represents and warrants that at all

times during the term of this Agreement, Practitioner will:

2.5.1 Be duly licensed to practice his or her profession under the laws and regulations of each

state in which Provider provides health care services and such license(s) will not have been

revoked, rescinded, limited, suspended or the equivalent;

2.5.2 Maintain any specialty Board certification such as required by the state of Massachusetts

for the delivery of covered Medicaid services.

2.5.3 Comply with all laws, regulations and other governmental directives applicable to

Provider;

2.5.4 Abide by the DSM/DentaQuest Office Reference Manual;

2.5.5 Furnish Covered Services to Members at all locations at which Provider(s) furnishes health

care services to individuals;

2.5.6 Maintain adequate medical records relating to the provision of health care services to

Members, consistent in form and content with applicable law and professional standards.

Provider shall maintain all medical records relating to Members for the greater of seven (7)

years or the length of time Practitioner is required to maintain patient records under

applicable state law, which obligations shall not terminate upon termination of this

Agreement.

2.5.7 Safeguard all information about Members according to applicable state and federal laws

and regulations. All material and information, in particular information relating to

Members or potential Members, which is provided to or obtained by or through Provider’s

performance under this Agreement, whether verbal, written, tape, or otherwise, shall be

reported as confidential information to the extent confidential treatment is provided under

state and federal laws. Provider shall not use any information so obtained in any manner

except as necessary for the proper discharge of his/her obligations and securement of

his/her rights under this Agreement. Neither DSM/DentaQuest nor Provider shall share

confidential information with a Member’s employer absent the Member’s consent for such

disclosure. Provider agrees to comply with the requirements of the Health Insurance

Portability and Accountability Act (“HIPAA”) relating to the exchange of information and

shall cooperate with DSM/DentaQuest in its efforts to ensure compliance with the privacy

regulations promulgated under HIPAA and other related privacy laws. Provider and

DSM/DentaQuest acknowledge that the activities conducted to perform the obligations

undertaken in this Agreement are or may be subject to HIPAA as well as the regulations

promulgated to implement HIPAA. Provider and DSM/DentaQuest agree to conduct their

respective activities, as described herein, in accordance with the applicable provisions of

HIPAA and such implementing regulations. Provider and DSM/DentaQuest further agree

that, to the extent HIPAA or such implementing regulations require amendments(s) hereto,

Provider and DSM/DentaQuest shall conduct good faith negotiations to amend this

Agreement. Provider shall maintain adequate dental/medical, financial and administrative

records related to covered dental services rendered by Provider in accordance with federal

and state law.

2.5.8 To cooperate and provide Plan, DSM/DentaQuest, government agencies and any external

review organizations (“Oversight Entities”) with access to each Member’s dental records

for the purposes of quality assessment, service utilization and quality improvement,



investigation of Member complaints or grievances or as otherwise is necessary or

appropriate

2.5.9 To provide such information and data, including, but not limited to, encounter, utilization,

referral and other data, that Oversight Entities may require.

2.5.10 To provide, at no cost to the Member or the Member’s new or different dental provider, all

Member’s dental/medical records.

2.5.11 That any and all Member records will be maintained for a period not less than seven (7)

years, or minimum required by state, following the termination of this Agreement or, if

such records are under review or audit, until such review or audit is complete.

2.5.12 That all records shall be made available for fiscal audit, medical audit, medical review,

utilization review and other periodic monitoring upon request of Oversight Entities at no

cost to the requesting entity.

2.5.13 Upon termination of this Agreement for any reason, to make available to any Oversight

Entities, in a useable form, all records, whether dental/medical or financial, related to

Provider’s activities undertaken pursuant to the terms of this Agreement at no cost to the

requesting entity.

2.5.14 That any Oversight Entities, including but not limited to DSS, the Attorney General of the

State of Massachusetts, the state fraud agency, the United States Department of Health and

Human Services ("HHS"), the Comptroller General of the United States, and/or their duly

authorized representatives shall have access to any books, documents, papers and records

which are related to this Agreement for the purpose of making audit, examination, excerpts

and transcriptions; provided, however, that those records detailing health care status and/or

treatment of specific Members eligible for coverage of health care/dental services under

Title XVIII of the Social Security Act need not be made available to the Comptroller

General of the United States.

2.5.15 That Provider shall allow duly authorized agents or representatives of Oversight Entities,

during normal business hours, access to Provider’s premises to inspect, audit, monitor or

otherwise evaluate the performance of Provider’s contractual activities and shall forthwith

produce all records requested as part of such review or audit. In the event right of access is

requested under this paragraph, Provider shall, upon request, provide and make available

staff to assist in the audit or inspection effort, and provide adequate space on the premises

to reasonably accommodate personnel conducting the audit or inspections effort. All

inspections or audits shall be conducted in a manner as will not unduly interfere with the

performance of Provider’s activities. All information so obtained will be accorded

confidential treatment as provided under applicable law. Oversight Entities and/or their

duly authorized representatives shall be allowed access to evaluate through inspection or

other means, the quality, appropriateness and timeliness of services performed under this

Agreement.

2.6 Authority of Provider – Provider represents and warrants that it has full authority to bind those

providers listed as Provider Dentist to the terms and conditions of this Agreement.

2.7 Clinical Laboratory Improvement Amendments – Provider shall refer all authorized laboratory tests

and procedures to a laboratory that has been issued (A) either a certificate of registration under The

Clinical Laboratory Improvement Amendments (“CLIA”), a certificate waiver under CLIA, or a

certificate of accreditation under CLIA, and (B) a CLIA identification number. A laboratory that has

been issued a certificate of waiver may only perform the tests and procedures permitted under its

waiver.



2.8 Appointment Status – Provider shall ensure Members are offered appointments; within 48 hours of

the Member’s request for Urgent Care, within 30 calendar days of the Member’s request for Non-

urgent, Symptomatic Care, and within 60 calendar days for Non-Symptomatic Care.

2.9 Practitioner Notification Responsibilities – Provider agrees to immediately notify the

DSM/DentaQuest of any of the following events related to the Provider:

2.9.1 The revocation, rescission, limitation, suspension or the equivalent of the licensure of the

Provider by any governmental agency or professional society, or medical staff privileges at

any hospital, or the requirement of supervision of the Provider, either through formal action

by the agency or society, or through any voluntary agreement;

2.9.2 Any criminal action brought against the Provider;

2.9.3 The existence and basis of any pending proceeding before a court, governmental or

regulatory body against Provider, instituted by any employer, governmental agency, health

care group or facility, professional review organization, or professional society which

involves any allegation of substandard conduct or professional misconduct; and

2.9.4 Any allegation of substandard conduct or professional misconduct raised against Provider,

during the term of this Agreement by any Member;

2.9.5 Provider must notify DSM/DentaQuest if they are excluded from participation in federal

health care programs by the Office of the Inspector General of the U.S. Department of

Health and Human Services under section 1128 or section 1128A of the Social Security

Act.

2.10 Referrals – Prior to making a referral, the Provider agrees to seek Authorization, if applicable in

accordance with the DSM/DentaQuest’s policies and procedures. Provider agrees to refer only to

Participating Providers that render covered specialty services (oral surgery, endodontics, prosthetics,

and orthodontics) that Provider does not perform, only to dental specialists designated by

DSM/DentaQuest.

2.11 Provider Listing – Provider agrees that the Provider's name and type of practice may be included on

DSM/DentaQuest's roster of Participating Providers.

2.12 Audits – DSM/DentaQuest will have the right, from time to time, to conduct, or have conducted by

a third party, audit and evaluation of Provider’s records and facilities with respect to claim

reimbursement and Covered Services provided to Members. Upon a fourteen (14) day notice,

Provider will cooperate with, and provide all information necessary or appropriate for, such audits

and evaluations. During reasonable office hours Provider will allow DSM/DentaQuest’s or a duly

authorized third party to inspect the Member’s medical records maintained by Provider per

DSM/DentaQuest’s Office Reference Manual.

2.13 Provider Dentist - Provider shall supply all information requested by DSM/DentaQuest for the

purpose of credentialing Provider Dentist, and Provider Dentist must be approved for participation

by DSM/DentaQuest in writing before rendering Covered Services to Members. Provider Dentist

shall have the rights and obligations provided in the Agreement, which are applicable to Provider,

and understands that certain provisions of the Agreement shall also be individually binding on

Provider Dentist, and that DSM/DentaQuest may require performance of all provisions by Provider

Dentist. Provider Dentist also understands that DSM/DentaQuest and Provider may amend the

Agreement without right of review by or approval of Provider Dentist. Provider Dentist agrees to

look solely to Provider for reimbursement of Covered Services, where Provider is designated as

payee pursuant to Agreement



2.14 Missed Appointment – Provider shall not bill, charge, collect a deposit from, seek compensation,

remuneration or reimbursement from or have any recourse against a Member or persons acting on

their behalf for missed appointments. Provider shall not be required to accept or continue treatment

of a Member with whom Provider feels he/she cannot establish and/or maintain a professional

relationship, or is beyond the scope of Provider’s expertise or ability.

3. Obligations of DSM/DentaQuest

3.1 Access to Care – DSM/DentaQuest shall conduct its administrative operations in a manner that does

not encourage Provider to jeopardize Member’s access to care or the appropriate delivery of

Covered Services to Members

3.2 Benefit Changes – DSM/DentaQuest shall notify Provider of changes in benefit provisions offered

by the Plan.

3.3 Credentialing – DSM/DentaQuest shall review Provider’s credentials according to its written

credentialing criteria which shall include, but not be limited to a review of the following: a current

valid state license; any history relative to any revocation, suspension, probationary status or other

disciplinary action regarding a license, registration or certification in Massachusetts or other states,

as applicable; a valid Drug Enforcement Agency and Controlled Substance certification/registration;

education and training consistent with the provision of services by Provider; evidence of any current

board certifications; evidence of malpractice/professional liability insurance; and history of

professional liability claims for those that resulted in settlements and/or judgments paid to the

claimant.

3.4 Directories – DSM/DentaQuest shall maintain a listing of Participating Providers and may include

Provider’s participation in Plan’s network in provider directories and/or other publications intended

for use of Members, subject to approval by Plan.

3.5 Operations – DSM/DentaQuest shall conduct the day-to-day administrative operations of

DSM/DentaQuest, including but not limited to: drafting and negotiating contracts and provider

agreements with Providers, making benefit determinations; conducting actuarial analyses; setting,

collecting and accounting for fixed periodic payments; processing claims; regulatory compliance

and reporting; and marketing DSM/DentaQuest.

3.6 Quality Improvement – DSM/DentaQuest shall operate, at its own expense, quality assurance,

utilization review and Member grievance programs.

3.7 Payment Processing – DSM/DentaQuest shall transmit payments to Provider in accordance with the

terms and conditions of this Agreement.

3.8 Regulatory Compliance – Provider and employees and agents must meet the minimum requirements

for participation in the Medicaid program as required by State and Federal regulations.

4. Professional Requirements

4.1 Licensure – Provider and employees or agents rendering services to Members shall be appropriately

licensed to render such services as required by state or federal law or regulatory agencies, and such

licenses shall be maintained in good standing. Provider shall provide DSM/DentaQuest a copy of

said license(s) upon execution of this Agreement.

4.2 Restriction of Licensure – Provider shall notify DSM/DentaQuest within two (2) business days of

the loss or restriction of his/her DEA permit or dentistry license or any other action that limits or

restricts Provider’s ability to practice dentistry.



4.3 Professional Training – Provider and all employees or agents rendering services to Members shall

possess the education, skills, training, physical and mental health status, and other qualifications

necessary to provide quality dental patient care.

4.4 Professional Standards – Provider and employees or agents rendering services to Members shall

provide dental care, which meets or exceeds the standard of care for dentists in the region and shall

comply with all standards for dentists as established by any state or federal law or regulation.

4.5 Continuing Education – Provider and employees or agents rendering services to Members shall

comply with continuing education standards as required by state or federal law or regulatory

agencies.

4.6 Regulatory Compliance – Provider must meet the minimum requirements for participation in the

Medicaid program as provided by the State.

5. Billing and Payment

5.1 Compensation – DSM/DentaQuest shall pay Provider according to the terms of Attachments to this

Agreement for Covered Services rendered to Member

5.2 Hold Harmless. Provider agrees and warrants that in no event, including, but not limited to,

nonpayment by DSM/DentaQuest, DSM/DentaQuest insolvency, or breach of this Agreement, shall

Provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement

from or have any recourse against any Member or persons acting on their behalf for providing

Covered Services. This provision does not prohibit Provider from seeking to collect co-insurance,

co-payments or deductibles from Members or fees for non-covered services delivered on a fee-for-

service basis to Members as well as services received by ineligible persons in accordance with the

terms of the applicable Plan Certificate. Provider agrees that they shall hold the Members harmless

and shall not bill the Member for non-covered services if the services are not covered as a result of

any error or omission by Provider.

Provider also agrees that this hold harmless and warranty provision herein shall:

1. survive the termination of the Agreement regardless of the cause giving rise to

termination, and

2. supersede any oral or written contract agreement heretofore entered into between

Provider, DSM/DentaQuest, Plan and Members or designees.

Provider shall have no claims against or seek payment from the Commonwealth Health Insurance

Connector Authority, (hereafter, “the Authority”) for any Covered Services rendered to a Member.

Instead, Providers shall look solely to DSM/DentaQuest for payment with respect to Covered

Services rendered to Members. Furthermore, Providers shall not maintain any action at law or in

equity against the Authority to collect any sums that are owed by DSM/DentaQuest under this

Agreement for any reason, even in the event that DSM/DentaQuest fails to pay for or becomes

insolvent or otherwise breaches the terms and conditions of this Agreement.

5.3 Prompt Payment – DSM/DentaQuest agrees to pay Complete Claims to Provider within forty-five

(45) calendar days of receipt of a Complete Claim. If DSM/DentaQuest fails to pay a clean claim

within forty-five (45) days or fails to comply with notification requirements for any claims related to

the provisions of health care services, DSM/DentaQuest shall pay, in addition to any reimbursement

for health care services provided , interest on such benefits, which shall accrue beginning forty-five

(45) days after the carrier’s receipt of request for reimbursement at the rate of 1.5 per cent per

month, not to exceed 18 per cent per year. The provisions relating to the interest payments shall not

apply to a claim that DSM/DentaQuest is investigating due to suspected fraud.



5.4 Confirmation of Eligibility – DSM/DentaQuest will maintain systems for confirming Member

eligibility, including without limitation making telephonic confirmation of eligibility available

during DSM/DentaQuest’s regular business hours. Confirmation of a Member's eligibility by

DSM/DentaQuest will not constitute a guaranty that all services provided by Provider will constitute

Covered Services; such confirmations will only guaranty payment for services rendered which are

ultimately determined to be Covered Services.

5.5 Provider Billing Information – Provider agrees to provide DSM/DentaQuest with the billing

information contained on Attachment A. Provider agrees to provide DSM/DentaQuest with sixty

(60) days written notice prior to any changes to the information on Attachment A.

5.6 Coordination of Benefits – DSM/DentaQuest and Provider shall cooperate and exchange

information regarding alternative health coverage of Members and other information relative to

coordination of benefits. DSM/DentaQuest will follow the Order of Benefit Determination Rules

promulgated from time to time by the Massachusetts Department of Business Regulation. If

DSM/DentaQuest has primary responsibility for payment, Provider shall accept reimbursement from

DSM/DentaQuest under this Agreement as full payment for Covered Services, except for Co-

payments or Deductibles. If DSM/DentaQuest has secondary responsibility for payment,

DSM/DentaQuest will pay no greater amount than that which, when added to amounts payable to

Provider from other sources under applicable coordination of benefit rules, equals one hundred

percent of Provider’s reimbursement for Covered Services due under this Agreement. If

DSM/DentaQuest has paid Provider when DSM/DentaQuest is not the primary payer, Provider

agrees to refund or allow deduction from future payments the amount of such overpayment.

5.6.1 Provider agrees to inquire of each Member to whom Provider provides Covered Services as

to the existence of any other group insurance or group benefit plan (including any coverage

under state or federal statutes) or other third party liability which may provide payment for

Covered Services rendered, and to cooperate with DSM/DentaQuest in processing such

claims.

5.6.2 Provider agrees to bill other payers first when Provider has reason to believe that

DSM/DentaQuest is likely not to be the primary payer for coordination of benefits

purposes.

5.6.3 DSM/DentaQuest will notify Provider in writing when DSM/DentaQuest will not pay

particular claims because other coverage appears to be primary.

5.7 Co-payment Limits and Member Charges For Noncovered Services – No deductibles or co-

payments are permitted for Medicaid Covered Services. A provider shall be permitted to charge an

eligible Member for goods or services which are not covered only if the Member knowingly elects

to receive the goods or services and enters into an agreement in writing to pay for such goods or

services prior to receiving them. For purposes of this section noncovered services are services not

covered under the Medicaid state plan, services which are provided in the absence of appropriate

authorization and services which are provided out-of-network unless otherwise specified in the

contract, policy or regulation (e.g., family planning, mental health or emergency room services.

5.8 Plan Reimbursement – Compensation of Provider by DSM/DentaQuest is subject to, and dependent

upon, DSM/DentaQuest’s receipt of proper claims payment from Plan. In the event of nonpayment

by Plan, DSM/DentaQuest reserves the right to withhold or recover payment to Provider for all

claims not paid by Plan. Once DSM/DentaQuest has received the outstanding amount for such

claims from Plan, DSM/DentaQuest will reimburse Provider according to the terms of this

Agreement. Provider agrees to accept electronic payment and electric remittance if/when available.

5.9 Continuation of Care – Provider agrees to complete any treatment in progress for continuation of

care cases and cases in mid-treatment for a newly enrolled Member. DSM/DentaQuest agrees to

negotiate fees in good faith for partial cases/treatment.



6. Term and Termination

6.1 Term and Renewal - This Agreement shall be effective on the Effective Date. The Agreement shall

thereafter continue for a term of twelve (12) months and shall automatically renew for successive

one (1) year periods unless terminated earlier in accordance with this Article.

6.2 Termination of Agreement for Cause – DSM/DentaQuest nor the Provider has the right to terminate

the Agreement without cause. DSM/DentaQuest shall notify Provider in writing of modifications in

payments, modifications in Covered Services or modifications in DSM/DentaQuest’s procedures,

documents or requirements, including those associated with utilization review, quality management

and improvement, credentialing, and preventive health services, that have a substantial impact on

the rights or responsibilities of the Provider, and the effective date of the modifications. The notice

shall be provided sixty (60) days before the effective date of such modification unless such other

date for notice is mutually agreed upon between DSM/DentaQuest and Provider. This Agreement

may be terminated by either party for cause at any time during the term of the Agreement upon sixty

(60) days prior written notice, unless the grounds for termination for cause have been remedied

during the notice period. DSM/DentaQuest shall provide a written statement to a Provider of the

reason(s) for such Provider’s involuntary termination. Grounds for termination for cause shall be:

6.2.1 Other party's failure to perform its obligations under this Agreement;

6.2.2 Provider's repeated and substantial delays in providing Covered Services, billing for such

Covered Services, or providing medical records or reports;

6.2.3 The loss or suspension of the dental license; or

6.2.4 The loss or suspension of Provider’s drug enforcement administration license, or the loss of

Provider’s unrestricted prescribing privileges; or

6.2.5 The loss of Provider’s liability insurance; or

6.2.6 Inability to participate without restriction in the Medicare or Medicaid program; or

6.2.7 Conduct of Provider deemed by DSM/DentaQuest’s Dental Director to be a danger to

Members’ health, provided termination for this basis may be immediate; or

6.2.8 Lack of need due to economic considerations, provided that termination for this basis shall

require no less than sixty (60) days prior written notice.

6.2.9 Filing of any petition seeking the voluntary bankruptcy, reorganization, liquidation or

similar proceeding of the non-terminating party or the filing of any involuntary bankruptcy,

reorganization, liquidation or similar proceeding against the non-terminating party and

such proceeding is not dismissed within sixty (60) days.

6.3 Termination Due to Proposed Amendment – Provider shall have the right to terminate this

Agreement on thirty (30) calendar days notice if Provider decides not to accept an amendment to

this Agreement. Such notice of termination must be made in writing by mail to DSM/DentaQuest at

the address in Section 10.10.

6.4 Continuity of Care – Termination of this Agreement shall not affect the method of payment or

reduce the amount of reimbursement to the Provider by DSM/DentaQuest for any patient in active

treatment for an acute medical condition at the time Provider terminates the contract with

DSM/DentaQuest until the active treatment is concluded or, if earlier, one (1) year after termination.

The Member hold harmless provisions of this Agreement shall continue in effect during the active

treatment period.



6.5 Member Notification – Provider shall give written notice of termination from the network within 15

business days after receipt or issuance of the termination notice, to each Member who received his

or her preventive dental care from Provider.

6.6 Due Process – In the event of any adverse decision by DSM/DentaQuest resulting in a change of

contractual privileges of Provider, DSM/DentaQuest shall notify Provider in writing of the

reasons(s) for the proposed actions and Provider shall be given the opportunity to appeal the actions

in line with the DSM/DentaQuest internal appeals process. The appeal, if requested, shall be

completed prior to the implementation of the proposed action. Additionally, Providers shall not be

required to waive their rights to appeal under this section as a condition of their contract. However,

should DSM/DentaQuest have reason to suspect that there is immediate danger to a Member,

DSM/DentaQuest and/or Plan shall immediately notify the Massachusetts Director of Health and

shall take appropriate action to protect Members.

7. Amendment and Arbitration

7.1 Amendment – DSM/DentaQuest may, in its sole discretion, amend or restate this Agreement from

time to time including without limitation its Attachments and Appendices. DSM/DentaQuest, by

providing the Provider with thirty (30) days prior written notice of the contents of the proposed

change. An explanation of the contractual changes, including the impact of the proposed changes in

non-technical terms, will be provided. If Provider desires not to accept a proposed amendment,

Provider’s sole recourse is to terminate this Agreement pursuant to Section 6.3 above.

7.2 Arbitration – The parties agree to negotiate in good faith and in a timely manner to attempt to

resolve any dispute regarding payment that may arise under this Agreement involving a contention

by one party that the other has failed to perform its obligation and responsibilities under this

Agreement. In the event a mutually satisfactory resolution cannot be reached and the matter does not

involve an issue in which DSM/DentaQuest’s policies and procedures DSM/DentaQuest grant

Provider specific due process rights, the parties agree to submit the matter to arbitration to be

conducted in accordance with the American Arbitration Association’s Commercial Arbitration

Rules, and judgment on the award rendered by the arbitrator may be entered in any court having

jurisdiction thereof.

8. Insurance and Indemnification

8.1 Insurance – Provider agrees that at all times during this Agreement Provider shall:

8.1.1 Maintain professional liability insurance in the minimum amounts required by the state of

Massachusetts in the aggregate covering Provider and each Provider employed or retained

by Provider who provides health care services to Members;

8.1.2 Maintain commercially reasonable amounts of general liability and such other insurance as

is ordinarily maintained by similarly qualified individuals or organizations; and

8.1.3 Require insurers to notify DSM/DentaQuest in writing at least thirty (30) days prior to any

cancellation or material change in Provider's professional or general liability insurance.

8.2 Indemnification – Each party shall indemnify and hold harmless the other from and against any and

all costs, expenses, debts, liabilities, damages, judgments and settlements (including reasonable

attorneys’ fees and legal costs) paid or incurred by the other as a result of, in connection with or

arising out of, any suit (in law and equity), claim, action, proceeding or investigation entered into or

brought or threatened against the other by any third party arising from either: (i) the negligent acts

or omissions or intentional misconduct of the indemnifying party, its employees, agents or invitees;

or (ii) the indemnifying party’s failure to perform its obligations under this Agreement.



9. Quality Management

9.1 Cooperation with Quality Programs – Provider shall cooperate with and participate in the utilization

review, quality assurance, credentialing, grievance, peer review, claims processing, and audit

procedures of DSM/DentaQuest, and shall comply with all final determinations rendered by such

procedures.

9.2 Re-credentialing – Provider shall cooperate with the re-evaluation of their credentials at such

intervals, as DSM/DentaQuest shall determine, but not more frequently than every two years. Such

evaluation may take into account a review of Provider's past performance and practice patterns, and

a review of dental records and evaluations pertaining to Provider's participation in the delivery of

dental care.

9.3 Plan and Regulatory Agency Oversight – The Provider acknowledges and agrees that nothing in the

Agreement shall be construed to limit: (a) the authority of the Plan to ensure the Provider’s

participation in and compliance with Plan’s quality assurance, utilization management, member

grievance and other systems and procedures; (b) any applicable regulatory agency’s authority to

monitor the effectiveness of such systems and procedures; or (c) Plan’s authority to sanction or

terminate a Provider found to be providing inadequate or poor quality care or failing to comply with

Plan’s systems, standards or procedures.

9.3.1 The Provider acknowledges and agrees that any delegation under a contract of quality

assurance, utilization management, credentialing, provider relations and other dental

management programs, shall be subject to Plan’s oversight and monitoring of

DSM/DentaQuest’s performance. The Provider further acknowledges and agrees that Plan,

upon the failure of DSM/DentaQuest to properly implement and administer such systems

or to take prompt corrective action after identifying quality, member satisfaction or other

problems, may terminate the contract and that, as a result of such termination, the

Provider’s participation in Plan may also be terminated.

10. Miscellaneous

10.1 Independent Contractors – Nothing herein is intended to create nor shall it be deemed or construed

to create any relationship between the parties hereto other than that of nonexclusive independent

contractors. Except as expressly provided herein, neither of the parties hereto shall be construed to

be the agent, employee, partner, co-venturer or owner of the other with respect to its performance

under this Agreement.

10.2 Waiver – Failure to insist on strict performance of any provision of this Agreement shall not

constitute a waiver of such provision. Waiver of a provision of this Agreement on any one occasion

shall not be deemed to be a waiver of any other provision of this Agreement or as a waiver of such

provision on any subsequent occasion.

10.3 Governing Law – This Agreement shall be governed by and construed in accordance with the laws

of the State of Massachusetts.

10.4 Non-exclusivity – This Agreement is not an exclusive contract and DSM/DentaQuest may contract

with other providers of dental services. Provider may contract with other dental plans. This

Agreement shall be regarded as confidential and its terms or contents shall not be disclosed to any

other party unless agreed to in writing by DSM/DentaQuest; except, however, Provider may

disclose the contents of this Agreement to the legal representative of Provider without the consent of

DSM/DentaQuest.

10.5 Change in Status – Provider understands that any and all changes in the Provider's legal and

contractual relationship to and with Provider's clinic partners, who are also party to this Agreement



must be communicated in writing to DSM/DentaQuest, or DSM/DentaQuest may elect to

immediately terminate this Agreement. Provider also agrees to provide DSM/DentaQuest with 30

days advance written notice of any closure of their practice to additional Members, or new location

at which Provider anticipates seeing Members.

10.6 Waiver of Breach – The waiver by either party of a breach of violation of any provision of the

Agreement shall not operate as or be construed to be a waiver of any subsequent breach hereof.

10.7 Responsibility for Actions – Each party shall be responsible for any and all claims, liabilities,

damages, or judgments that may arise as a result of its own negligence or intentional wrongdoing.

10.8 Severability – The invalidity or unenforceability of any term of condition shall in no way affect the

validity or enforceability of the remainder of this Agreement.

10.9 Assignment – DSM/DentaQuest may assign this Agreement immediately upon written notice to

Provider. Provider must obtain DSM/DentaQuest’s prior written consent to assign this Agreement.

10.10 Notice – Any notices required to be given pursuant to the terms and provision hereof shall be sent

by mail, addressed to DSM/DentaQuest at:

Dental Service of Massachusetts/DentaQuest, Inc

Attn: Provider Information

12121 N. Corporate Parkway

Mequon, WI 53092

and to the Provider at the address stated herein or as he/she may otherwise notify DSM/DentaQuest

in writing.

10.11 Form – All words used herein in the singular number shall extend to and include the plural. All

words used in the plural numbers shall extend to and include the singular. All words used in any

gender shall extend to and include all genders.

10.12 Entire Agreement – This Agreement, together with all subordinate and other documents and exhibits

incorporated herein, constitutes the final and entire expression of the Agreement between the parties

with respect to the subject matter contained herein and expressly supercedes all prior and

contemporaneous representations, statements, drafts, correspondence or similar understanding or

documents.

10.13 Errors – DSM/DentaQuest shall make every effort to maintain accurate information; however,

DSM/DentaQuest shall not be held liable for any damages directly or indirectly due to typographical

errors. The Provider agrees to immediately notify DSM/DentaQuest of any errors found on

remittance statements



IN WITNESS WHEREOF, the parties hereto have executed this Agreement on the date written below:

Legal Entity Name & Address Dental Service of Massachusetts, Inc.

Name___________________________________

(Business Entity Name as on W-9)

Address__________________________________

__________________________________

Phone __________________________________

BY: _____________________________________ BY: ________________________________

(Signature) Fay Donahue

President & CEO

BY: _____________________________________

(Please Print or Type Name)

Tax ID #__________________________________

Group NPI # ______________________________

DATE: _______/_______/_______ DATE: _______/_______/_______

PROVIDER DENTISTS

(Please Type or Print)

Please list the name of all individual dentists providing services under the terms of this Agreement.

________________________ ________________________ ________________________

Dentist Name Specialty Medicaid Number

________________________ ________________________ ________________________


________________________ ________________________ ________________________


________________________ ________________________ ________________________


________________________ ________________________ ________________________


________________________ ________________________ ________________________




** THIS PAGE IS INTENTIONALLY LEFT BLANK**

140501 MA SWH MDCR A-1


ATTACHMENT A

DENTAL PANEL REIMBURSEMENT

SENIOR WHOLE HEALTH

1.00 Provider shall be reimbursed for Covered Services rendered to Members at the lesser of billed charges or

one hundred percent (100%) of the Attached Fee Schedule as shown in Attachment A-1 of this Agreement

for Covered Services to eligible Senior Whole Health Members.

2.00 Provider agrees to practice cost effective dentistry. Provider acknowledges that improper billing or the

rendering of dental care that is determined to be unnecessary or inappropriate by the DSM/DentaQuest

Dental Director, shall not be compensated and will constitute sufficient basis for termination of this

agreement or other measures as described in paragraph 3.00.

3.00 Provider acknowledges that “fee-for-service” dental reimbursement can only be maintained with the

cooperation and commitment of all dental panel members to practice cost effective, quality dentistry.

DSM/DentaQuest shall compile an internal “practice profile” for each member of the DSM/DentaQuest

dental panel on a periodic basis. This profile will compute averages for total cost per patient. Providers,

whose practice patterns deviate in a statistically significant way from the norms of the DSM/DentaQuest

dental panel, may be subject to notice of probationary status and/or possible termination, subject to the

appropriate notice and appeal procedures as stated herein.

4.00 DSM/DentaQuest does not offer any financial incentives to Provider conducting review to reduce, delay, or

limit specific covered services.

5.00 DSM/DentaQuest shall pay Provider within forty-five (45) calendar days of receipt of clean claims for

dental services rendered to Members. Provider agrees to accept electronic payment and electronic

remittances.

6.00 Provider shall submit a complete claim for payment to DSM/DentaQuest within ninety (90) days of the

date services are provided to Senior Whole Health Members. Claims shall be submitted in a format

acceptable to DSM/DentaQuest as specified in the DSM/DentaQuest Office Reference Manual. Provider

shall submit claims electronically to DSM/DentaQuest. If unable to submit claims electronically, paper

claims must be submitted on a standard ADA claim form or a format that has been approved by

DSM/DentaQuest in advance. If DSM/DentaQuest determines that a claim is not complete,

DSM/DentaQuest will notify Provider in writing of the reason for denying or pending the claim and what

additional information, if any, is required to process the claim. Provider agrees that DentaQuest can adjust

future payments or request Provider refund an amount equal to any payment made to Provider in error by

DentaQuest including but not limited to an overpayment, duplicate payment, an ineligible member or for

any other reason for which payment should not have initially been made.

7.00 Provider reimbursement requires receipt of a Complete Claim. A claim shall be considered complete only if

the claim requires no further information, documentation, adjustment or alteration by Provider to be

adjudicated by DSM/DentaQuest. Any dispute regarding payment shall be deemed waived unless Provider

submits written notification of the reasons for the dispute within ninety (90) days of receipt of the payment,

statement of denial or adjustment.

8.00 Provider has ninety (90) days from the date of such notice to make it a complete claim and resubmit it to

DSM/DentaQuest. Notwithstanding the foregoing, there shall be no time limit on claims if Provider’s

failure to comply is caused by a directive from a court or federal or state agency or is due to matters beyond

the Provider’s control and not caused by the Provider. Providers that utilize third party billers are

responsible for conducting oversight on such third party billers and ensuring that the third party biller

adheres to the contractual time frames established in this Section. Notwithstanding any other provisions of

this Section, if Provider has submitted a claim to another payer and through application of coordination of

benefits principles DSM/DentaQuest is subsequently determined to have primary responsibility for paying

the claim, DSM/DentaQuest will pay Complete Claims submitted by Provider to DSM/DentaQuest within

ninety (90) days of the date Provider received notice from the other payer that the payer declined payment

because they believed DSM/DentaQuest was the primary payer.

140501 MA SWH MDCR A-2


** THIS PAGE IS INTENTIONALLY LEFT BLANK**

140501 MA SWH MDCR A-1-1


ATTACHMENT A-1

SENIOR WHOLE HEALTH

SCHEDULE OF ALLOWABLE FEES **PLEASE REFER TO OFFICE REFERENCE MANUAL ON DENTAQUEST’S WEBSITE FOR COVERED SERVICES**

Code Description Fee

D0120 Periodic oral examination $23.00

D0140 Limited oral evaluation-problem

focused $40.00

D0150 Comprehensive oral evaluation –

new or established patient $37.00

D0160 Detailed & extensive oral evaluation -

problem focused, by report $60.00

D0210 Intraoral – complete series (including

bitewings) $75.00

D0220 Intraoral – periapical, first film $14.00

D0230 Intraoral – periapical, each additional

film $12.00

D0270 Bitewing - single film $13.00

D0272 Bitewings - two films $22.00

D0273 Bitewing - three films $33.00

D0274 Bitewings - four films $33.00

D0330 Panoramic film $62.00

D0340 Cephalometric film $69.00

D0350 Oral/facial images $36.00

D0470 Diagnostic casts $58.00

D1110 Prophylaxis - adult $49.00

D1208 Topical application of fluoride

(prophylaxis $29.00

D1510 Space maintainer - fixed-unilateral $178.00

D1515 Space maintainer - fixed-bilateral $285.00

D1520 Space maintainer - removable-

unilateral $214.00

D1525 Space maintainer - removable-

bilateral $321.00

D2140 Amalgam - one surface, primary or

permanent $58.00

D2150 Amalgam - two surfaces, primary or

permanent $72.00

D2160 Amalgam - three surfaces, primary or

permanent $86.00

D2161 Amalgam - four or more surfaces,

primary or permanent $108.00

D2330 Resin-based composite - one

surface, anterior $67.00

D2331 Resin-based composite - two

surfaces, anterior $86.00

D2332 Resin-based composite - three

surfaces, anterior $108.00

D2335 Resin-based composite - 4 + srfs/

involve incisal angle (anterior) $136.00

D2390 Resin-based composite crown,

anterior $99.00

D2391 Resin-based composite – one

surface, posterior $51.00


D2392 Resin-based composite – two

surfaces, posterior $65.00

D2393 Resin-based composite – three


D2394 Resin-based composite – 4+


D2710 Crown – resin- based composite

(indirect) $214.00

D2720 Crown - resin with high noble metal $571.00

D2721 Crown - resin with predominantly

base metal $571.00

D2722 Crown - resin with noble metal $571.00

D2740 Crown - porcelain/ceramic substrate $571.00

D2750 Crown - porcelain fused to high noble

metal $571.00

D2751 Crown - porcelain fused to predominantly base metal

$571.00

D2752 crown - porc/metal noble $571.00

D2780 Crown - 3/4 cast high noble metal $571.00

D2783 Crown - 3/4 porcelain/ceramic $571,00

D2790 Crown - full cast high noble metal $571.00

D2791 Crown - full cast predominantly base

metal $571.00

D2792 Crown - full cast noble metal $571.00

D2910 Recement inlay, onlay, or partial

coverage restoration $53.00

D2920 Recement crown $53.00

D2951 Pin retention - per tooth, in addition

to restoration $25.00

D2952 cast post & core $217.00

D2954 Prefabricated post and core in

addition to crown $178.00

D2980 Crown repair, by report $107.00

D3310 Anterior (excluding final restoration) $375.00

D3320 Bicuspid (excluding final restoration) $440.00

D3330 Molar (excluding final restoration) $569.00

D3410 Apicoectomy/periradicular surgery -

anterior $379.00

D3346 Retreatment of previous root canal

therapy - anterior $425.00


therapy - bicuspid $501.00


therapy - molar $571.00

D3421 Apicoectomy/periradicular surgery -

bicuspid (first root) $429.00

D3426 Apicoectomy/periradicular surgery

(each additional root) $214.00




D4210 Gingivectomy or gingivoplasty – 4+ contiguous teeth or bounded teeth

spaces, per quadrant $286.00

D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or bounded

teeth spaces , per quadrant $103.00

D4341 Periodontal scaling and root planing,

4+ teeth, per quadrant $125.00

D4342 Periodontal scaling and root planing,

1-3 teeth, per quadrant $84.00

D4355 Full mouth debridement to enable

comprehensive and diagnosis $72.00

D5110 Complete denture - maxillary $680.00

D5120 Complete denture - mandibular $680.00

D5211 Maxillary partial denture - resin base (including any conventional clasps,

rests and teeth) $518.00

D5212 Mandibular partial denture - resin base (including any conventional

clasps, rests and teeth) $554.00

D5510 Repair broken complete denture

base $79.00

D5520 Replace missing or broken teeth -

complete denture (each tooth) $72.00

D5610 Repair resin denture base $72.00

D5620 Repair cast framework $97.00

D5630 Repair or replace broken clasp $92.00

D5640 Replace broken teeth - per tooth $72.00

D5650 Add tooth to existing partial denture $86.00

D5660 Add clasp to existing partial denture $91.00

D5710 Rebase complete maxillary denture $236.00

D5711 Rebase complete mandibular

denture $187.00

D5720 Rebase maxillary partial denture $214.00

D5750 Reline complete maxillary denture

(laboratory) $199.00

D5751 Reline complete mandibular denture


D5760 Reline maxillary partial denture


D5761 Reline mandibular partial denture


D6010 Surgical placement of implant $1,072.00

D6210 Pontic-cast high noble metal $607.00

D6211 Pontic-cast predominantly base

metal $544.00

D6212 Pontic-cast noble metal $589.00

D6240 Pontic-porcelain fused to high noble

metal $625.00

D6241 Pontic-porcelain fused to predominantly base metal

$565.00

D6242 Pontic-porcelain fused to noble metal $571.00

D6250 Pontic-resin with high noble metal $655.00

D6251 Pontic-resin with predominantly base

metal $482.00


D6252 Pontic-resin with noble metal $517.00

D6545 Retainer-cast metal for resin bonded

fixed prosthesis $250.00

D6930 Recement fixed partial denture $67.00

D7111 Extraction, coronal remnants –

deciduous tooth $70.00

D7140 Extraction, erupted tooth or exposed

root (elevation and/or forceps removal)

$70.00

D7210

Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap& removal of bone and/or section

of tooth

$139.00

D7220 Removal of impacted tooth - soft

tissue $178.00

D7230 Removal of impacted tooth - partially

bony $232.00

D7240 Removal of impacted tooth -

completely bony $275.00

D7250 Surgical removal of residual tooth

roots $134.00

D7270 Tooth reimplantation and/or

stabilization of accidentally evulsed or displaced tooth

$99.00

D7310 Alveoloplasty in conjunction with

extractions - per quadrant $132.00

D7311 Alveoloplasty in conjunction with extractions - 1 - 3 teeth or tooth

spaces - per quadrant $119.00

D7320 Alveoloplasty not in conjunction with

extractions - per quadrant $174.00

D7321 Alveoloplasty not in conjunction with

extractions - 1 - 3 teeth or tooth spaces - per quadrant

$139.00

D7340 Vestibuloplasty - ridge extension

(second epithelialization) $696.00

D7350

Vestibuloplasty - ridge extension (incl soft tissue grafts, muscle

reattachments, revision of soft tissue attachment & management of

hypertrophied & hyperplastic tissue)

$879.00

D7410 Excision of benign lesion up to 1.25

cm $107.00

D7411 Excision of benign lesion, greater

than 1.25cm $194.00

D7450 Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25

cm $231.00

D7451 Removal of benign odontogenic cyst

or tumor - lesion diameter greater than 1.25 cm

$268.00

D7460 Removal of benign nonodontogenic cyst or tumor - lesion diameter up to

1.25 cm $113.00

D7461 Removal of benign nonodontogenic

cyst or tumor - lesion diameter greater than 1.25 cm

$133.00

D7471 Removal of lateral exostosis (maxilla

or mandible) $133.00

D7960 Frenulectomy (frenectomy or

frenotomy) - separate procedure $100.00

D7963 frenuloplasty $388.00

D7970 Excision of hyperplastic tissue - per

arch $229.00




D8692 Replacement of lost or broken

retainer $79.00

D9110 Palliative (emergency) treatment of

dental pain - minor procedure $33.00

D9220 General anesthesia - first 30 minutes $114.00

D9221 General anesthesia -each additional

15 minutes $89.00

D9230 Analgesia, anxiolysis, inhalation of

nitrous oxide $17.00

D9241 Intravenous sedation/analgesia-first

30 minutes $178.00

D9242 Intravenous sedation/analgesia -

each additional 15 minutes $73.00

D9248 Non-intravenous conscious sedation $45.00

D9410 House/extended care facility call $22.00

D9920 Behavior management, by report $42.00

Medicare Requirements 1


MEDICARE REQUIREMENTS

Provider agrees to the following terms and conditions as they pertain to services rendered to Members enrolled in an

applicable Medicare Advantage Plan. Since the Agreement between Provider and DentaQuest, in whole or in part,

relates to services provided to Medicare Advantage Members, you are required by Centers for Medicare and

Medicaid Services (“CMS”), contracted Plan, and DentaQuest, to agree to and comply with the following

requirements.

For purposes of this Medicare Requirements Attachment, reference to “Provider” means the individual or entity

identified as a named party to the Agreement, its employees, contractors and/or subcontractors and those individuals

or entities performing administrative services for or on behalf of Provider and/or any of the above referenced

individuals or entities performing services related to the Agreement. Provider acknowledges that the requirements

contained in this Attachment shall apply equally to the above referenced individuals or entities and that Provider’s

agreements with such individuals or entities shall contain the applicable Medicare requirements set forth in this

Attachment. In the event of a conflict between any provision in this Attachment and such agreement, this

Attachment will control.

Except as specifically amended hereby, the terms and conditions of the Agreement remain the same. In the event of

a conflict between the Agreement and this Attachment, this Attachment will control with respect to Members of

Medicare Advantage Plans.

1. Compliance with Law. Provider acknowledges that payment received for providing Covered Services to

Members under the Agreement, in whole or in part, are deemed to be federal funds subject to all laws and

regulations applicable to recipients of federal funds. As such, Provider agrees to comply with all applicable

Medicare laws, rules and regulations, reporting requirements, CMS instructions, and applicable requirements of the

contract between Plan and CMS (the “Medicare Contract”) and with all other applicable state and federal laws and

regulations, as may be amended from time to time, including, without limitation: (1) Federal laws and regulations

designed to prevent or ameliorate fraud, waste, and abuse, including, but not limited to, applicable provisions of

Federal criminal law, the False Claims Act (31 U.S.C. 3729 et. seq.), and the anti-kickback statute (section

1128B(b)) of the Act); and (2) the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”)

administrative simplification rules at 45 CFR parts 160, 162, and 164. [42 C.F.R. § 422.504(h)].

2. Medicare Advantage Member Privacy and Confidentiality. Provider agrees to comply with all state and

federal laws, rules and regulations, Medicare program requirements, and/or requirements in the Medicare Contract

regarding privacy, security, confidentiality, accuracy and/or disclosure of records (including, but not limited to,

medical records), personally identifiable information and/or protected health information and enrollment

information including, without limitation: (1) HIPAA and the rules and regulations promulgated thereunder, (2) 42

C.F.R. § 422.504(a)(13), and (3) 42 C.F.R. § 422.118; (iv) 42 C.F.R. § 422.516 and 42 C.F.R. § 422.310 regarding

certain reporting obligations to CMS. Provider also agrees to release such information only in accordance with

applicable state and/or federal law or pursuant to court orders or subpoenas.

3. Audits; Access to and Maintenance of Records. Provider shall permit inspection, evaluation and audit directly

by DentaQuest, Plan, the Department of Health and Human Services (DHHS), the Comptroller General, the Office

of the Inspector General, the General Accounting Office, CMS and/or their designees, and as the Secretary of the

DHHS may deem necessary to enforce the Medicare Contract, physical facilities and equipment and any pertinent

information including books, contracts (including any agreements between Provider and its employees, contractors

and/or subcontractors providing services related to the Agreement), documents, papers, medical records, patient care

documentation and other records and information involving or relating to the provision of services under the

Agreement, and any additional relevant information that CMS may require (collectively, “Books and Records”). All

Books and Records shall be maintained in an accurate and timely manner and shall be made available for such

inspection, evaluation or audit for a time period of not less than ten (10) years, or such longer period of time as may

be required by law, from the end of the calendar year in which expiration or termination of this Agreement occurs or

from completion of any audit or investigation, whichever is greater, unless CMS, an authorized federal agency, or

such agency’s designee, determines there is a special need to retain records for a longer period of time, which may

include but not be limited to: (i) up to an additional six (6) years from the date of final resolution of a dispute,

allegation of fraud or similar fault; or (ii) completion of any audit should that date be later than the time frame(s)



indicated above; (iii) if CMS determines that there is a reasonable possibility of fraud or similar fault, in which case

CMS may inspect, evaluate, and audit Books and Records at any time; or (iv) such greater period of time as

provided for by law. Provider shall cooperate and assist with and provide such Books and Records to DentaQuest,

Plan and/or CMS or its designee for purposes of the above inspections, evaluations, and/or audits, as requested by

CMS or its designee and shall also ensure accuracy and timely access for Members to their medical, health and

enrollment information and records. Provider agrees and shall require its employees, contractors and/or

subcontractors and those individuals or entities performing administrative services for or on behalf of Provider

and/or any of the above referenced individuals or entities: (i) to provide DentaQuest, Plan and/or CMS with timely

access to records, information and data necessary for: (1) Plan to meets its obligations under its Medicare

Contract(s); and/or (2) CMS to administer and evaluate the MA program; and (ii) to submit all reports and clinical

information required by the Plan under the Medicare Contract. [42 C.F.R. § 422.504(e)(4), (h), (i)(2), and (i)(4)(v).]

In accordance with applicable law: (1) nothing in this agreement or any other agreement shall be construed to limit:

(a) the authority of DentaQuest or the Plan to ensure participation in and compliance with its quality assurance,

utilization management, member grievance and other systems and procedures; (b) the DHHS’ authority to monitor

the effectiveness of the Plan’s systems and procedures, or to require the Plan to take prompt corrective action

regarding quality of care or Member appeals, grievances and complaints; (c) DentaQuest or Plan’s authority to

sanction or terminate a provider found to be providing inadequate or poor quality care or failing to comply with

DentaQuest or Plan’s systems, standards or procedures; and (2) Provider shall participate and abide by the decisions

of DentaQuest and/or Plan’s medical policy, quality assurance, medical management, utilization review, member

grievance and Medicare’s appeal system.

Where applicable, Provider will participate in the collection and submission of data to CMS which includes, but is

not limited to the following: (a) impatient hospital data for discharges; (b) physician, outpatient hospital skilled

nursing facility and home health agency data; and (c) all other data CMS deems necessary. Provider shall certify the

accuracy of he data that is collected and submitted to CMS where applicable.

4. Prompt Payment of Claims. DentaQuest and/or Plan and/or Provider, as applicable, agree to process and pay or

deny claims for Covered Services within thirty (30) calendar days of receipt of such claims in accordance with the

Agreement. [42 C.F.R. § 422.520(b).]

5. Hold Harmless of Members. Provider hereby agrees: (i) that in no event, including but not limited to, non-

payment by DentaQuest or Plan, DentaQuest or Plan’s determination that services were not Medically Necessary,

DentaQuest or Plan insolvency, or breach of the Agreement, shall Provider bill, charge, collect a deposit from, seek

compensation, remuneration or reimbursement from, or have any recourse against a Member for amounts that are

the legal obligation of DentaQuest or Plan; and (ii) that Members shall be held harmless from and shall not be liable

for payment of any such amounts. Provider further agrees that this provision (a) shall be construed for the benefit of

Members; (b) shall survive the termination of this Agreement regardless of the cause giving rise to termination, and

(c) supersedes any oral or written contrary agreement now existing or hereafter entered into between Provider and

Members, or persons acting on behalf of a Member. [42 C.F.R. § 422.504(g)(1)(i) and (i)(3)(i).]

Provider may notify a Member that certain medical services have been determined to be non-Covered Services

according to the terms of the Plan and may, if the Member desires, make independent financial arrangements in

advance, with written documentation thereof, and collect from such Member for such non-Covered Services. In the

event that any charges for services which are determined to be non-Covered Services are billed by Provider to

DentaQuest, Plan or to a Member who has not agreed in advance in writing to independent financial arrangements

and payment is made by DentaQuest, Plan or Member, Provider shall immediately, upon request by DentaQuest,

Plan and/or Member, refund to DentaQuest, Plan or Member the full amount collected by Provider attributable to

non-Covered Service.

As required by 42 C.F.R. § 1001.952(m)(1)(i), in the case of services furnished to Members, Provider shall not

claim payment in any form from CMS or from any other agency of the United States or from any state for items and

services furnished in accordance with the Agreement, except as may be approved by CMS or a State agency, nor

shall Provider otherwise engage in any shifting of costs or seek increased payments from the Medicare Advantage

Program or any State health care program as a result of furnishing such services to Members.



6. Accountability. DentaQuest and Provider hereby acknowledge and agree that Plan shall oversee the provision of

services by Provider and DentaQuest and shall be accountable under the Plan’s Medicare Contract for services

provided to Members under the Agreement regardless of the provisions of the Agreement or any delegation of

administrative activities or functions to Provider under the Agreement. [42 C.F.R. § 422.504(i)(1); (i)(4)(iii); and

(i)(3)(ii).]

7. Delegated Activities. Provider acknowledges and agrees that to the extent DentaQuest, in its sole discretion,

elects to delegate any administrative activities or functions to Provider, Provider understands and agrees that: (i)

Provider may not delegate, transfer or assign any of Provider’s obligations under the Agreement and/or any separate

delegation agreement without DentaQuest’s prior written consent; and (ii) Provider must demonstrate, to

DentaQuest’s satisfaction, Provider’s ability to perform the activities to be delegated and the parties will set out in

writing: (1) the specific activities or functions to be delegated and performed by Provider; (2) any reporting

responsibilities and obligations pursuant to DentaQuest’s or Plan’s policies and procedures and/or the requirements

of the Medicare Contract; (3) monitoring and oversight activities by DentaQuest or Plan including without limitation

review and approval by DentaQuest or Plan of Provider’s credentialing process, as applicable, and audit of such

process on an ongoing basis; and (4) corrective action measures, up to and including termination or revocation of the

delegated activities or functions and reporting responsibilities if CMS or DentaQuest or Health Plan determines that

such activities have not been performed satisfactorily. [42 C.F.R. § 422.504(i)(3)(iii); 422.504(i)(4)(i)-(v).]

The parties agree, notwithstanding anything set forth in the Agreement, that the Plan oversees and is accountable to

CMS for any functions or responsibilities that are described in the CMS regulations.

8. Compliance with DentaQuest and Health Plan Policies and Procedures. Provider shall comply with all

policies and procedures of DentaQuest and Plan including, without limitation, written standards for the following:

(a) timeliness of access to care and member services; (b) policies and procedures that allow for individual medical

necessity determinations (e.g., coverage rules, practice guidelines, payment policies); (c) provider consideration of

Member input into Provider’s proposed treatment plan; and (d) Plan’s compliance program which encourages

effective communication between Provider and Plan’s Compliance Officer and participation by Provider in

education and training programs regarding the prevention, correction and detection of fraud, waste and abuse and

other initiatives identified by CMS. The aforementioned policies and procedures are identified in DentaQuest and

Plan Provider Manuals which are incorporated herein by reference and may be amended from time to time by

DentaQuest or Plan. [42 C.F.R. § 422.112; 422.504(i)(4)(v); 42 C.F.R. § 422.202(b); 42 C.F.R. § 422.504(a)(5); 42

C.F.R. § 422.503(b)(4)(vi)(C) & (D) & (G)(3).]

Provider shall report in writing to Plan within thirty calendar days of Provider’s knowledge any and all civil

judgments and “other adjudicated actions or decisions” against Provider related to the delivery of any health care

item or service (regardless of whether the civil judgment or other adjudicated action or decision is the subject of a

pending appeal). “Other adjudicated actions or decisions” means formal or official final actions taken against a

health care provider by a federal or state governmental agency or a health plan, which include the availability of a

due process mechanism, and are based on acts or omissions that affect or could affect the payment, provision, or

delivery of a health care item or service. An action taken following adequate notice and hearing requirement that

meets the standards of due process set out in section 412(b) of the Health Care Quality Improvement Act (42 U.S.C.

§ 11112(b)) also would qualify as a reportable action under this definition. The fact that Provider elects not to use

the due process mechanism provided by the authority bringing the action is immaterial, as long as such a process is

available to the subject before the adjudicated action or decision is made final.

9. Continuation of Benefits. Provider agrees that except in instances of immediate termination by DentaQuest or

Plan for reasons related to professional competency or conduct and upon expiration or termination of the

Agreement, Provider will continue to provide Covered Services to Members as indicated below and to cooperate

with DentaQuest or Plan to transition Members to other participating Providers in a manner that ensures medically

appropriate continuity of care. In accordance with the requirements of the Medicare Contract, DentaQuest’s or

Plan’s accrediting bodies and applicable law and regulation, Provider will continue to provide Covered Services to

Members after the expiration or termination of the Agreement, whether by virtue of insolvency or cessation of

operations of DentaQuest or Health Plan, or otherwise: (i) for those Members who are confined in an inpatient

facility on the date of termination until discharge; (ii) for all Members through the date of the applicable Medicare

Contract for which payments have been made by CMS to DentaQuest or Plan; and (iii) for those Members



undergoing active treatment of chronic or acute medical conditions as of the date of expiration or termination

through their current course of active treatment not to exceed ninety (90) days unless otherwise required by item (ii)

above. [42 C.F.R. 422.504(g)(2) & (3).]

10. Physician Incentive Plans. The parties agree: (i) that nothing contained in the Agreement nor any payment

made by DentaQuest or Plan to Provider is a financial incentive or inducement to reduce, limit or withhold

Medically Necessary services to Members; and (ii) that any incentive plans between DentaQuest or Plan and

Provider and/or between Provider and its employed or contracted physicians and other health care practitioners

and/or providers shall be in compliance with applicable state and federal laws, rules and regulations and in

accordance with the Medicare Contract. Upon request, Provider agrees to disclose to DentaQuest or Plan the terms

and conditions of any “physician incentive plan” as defined by CMS and/or any state or federal law, rule or

regulation. [42 C.F.R. § 422.208.]

11. Termination. Notwithstanding any provision regarding termination, no termination of this Agreement without

cause or requested by Provider shall be effective unless made in advance in writing to DentaQuest, not less than

ninety (90) days prior to the anniversary date of the Agreement. DentaQuest, the Plan or its designee may terminate

Provider from this Product upon ninety (90) days advance written notice to Provider. If in DentaQuest or Plan’s

judgment, Provider has failed to cooperate with and abide by the decisions of DentaQuest or Plan’s medical policy,

quality assurance, medical management, utilization review, member grievance and Medicare’s appeal systems, or is

found to be harming Members, or if the continuation or participation negatively effects patient care, Provider’s

participation in this Product may be terminated. Nothing set forth herein shall limit the ability of the Plan to delegate

all or a portion of these functions. DentaQuest or Plan hereby agrees to provide notice to Provider when DentaQuest

or Plan denies, suspends, or terminates the Agreement with Provider and include: (a) the reason for the action, (b)

the standards and profiling data DentaQuest or Plan used to evaluate Provider, (c) the numbers and mix of health

care professionals needed for DentaQuest or Plan to provide adequate access to services, and (d) Provider’s right to

appeal the action and the timing for requesting a hearing.

12. Treatment Standards. Provider agrees to provide, in a manner consistent with professionally recognized

standards of health care, all benefits covered by the Plan. Provider shall provide Covered Services to Members in

accordance with the same standards and within the same time frames as generally provided by Provider to other

patients that are not Members and to not differentiate or discriminate in the treatment of or in the quality of services

delivered to Members on the basis of age, race, color, national origin, religion, handicap, ancestry or marital status,

any factor that is related to health status, or participation in the Medicare Program. Factors related to health status

include, but are not limited to the following: (a) medical condition, including mental as well as physical illness; (b)

claims experience; (c) receipt of health care; (d) medical history; (e) genetic information; (f) evidence of

insurability, including conditions arising out of acts of domestic violence; and (g) disability.

14. Credentialing. To participate in any product offered to Medicare Members, Provider must meet the

credentialing standard established by DentaQuest and Plan.

15. Exclusion. Provider shall not employ or contract for the provision of health care, utilization review, medical

social work, or administrative services with any individual excluded from participation in Medicare under section

1128 and 1128A of the Social Security Act. Provider hereby certifies that no such excluded person currently is

employed by or under contract with Provider relating to the furnishing of these services to Members. Providers that

are facilities, including Participating Hospitals, must be Medicare certified. All other Providers must be Medicare

participating providers. Participating Providers shall notify DentaQuest upon any change in such status.

16. Initial Assessment. As applicable, Provider shall cooperate with Plan in furnishing an initial assessment of

new Members’ heath care needs within 90 days of their enrollment.

ACH Authorization 1


AUTHORIZATION TO HONOR DIRECT AUTOMATED CLEARING HOUSE (ACH) CREDITS

DISBURSED BY DENTAQUEST, LLC

INSTRUCTIONS

1. Complete all parts of this form.

2. Execute all signatures where indicated. If account requires counter signatures, both signatures must appear on this

form.

3. IMPORTANT: Attach voided check from checking account.

MAINTENANCE TYPE:

__________ Add

__________ Change (Existing Set Up)

__________ Delete (Existing Set Up)

ACCOUNT HOLDER INFORMATION:

Account Number: ________________________________________________________________________

Account Type: __________ Checking

__________ Personal __________ Business (choose one)

Bank Routing Number:

Bank Name: ____________________________________________________________________________

Account Holder Name: ___________________________________________________________________

Effective Start Date: _____________________________________________________________________

As a convenience to me, for payment of services or goods due me, I hereby request and authorize DentaQuest, LLC to credit my

bank account via Direct Deposit for the (agreed upon dollar amounts and dates.) I also agree to accept my remittance statements

online and understand paper remittance statements will no longer be processed.

This authorization will remain in effect until revoked by me in writing. I agree you shall be fully protected in honoring any such

credit entry.

I understand in endorsing or depositing this check that payment will be from Federal and State funds and that any falsification, or

concealment of a material fact, may be prosecuted under Federal and State laws.

I agree that your treatment of each such credit entry, and your rights in respect to it, shall be the same as if it were signed by me.

I fully agree that if any such credit entry be dishonored, whether with or without cause, you shall be under no liability

whatsoever.

____________________________________ ___________________________________________

Date Print Name

________________________________________ ________________________________________________

Phone Number Signature of Depositor (s) (As shown on Bank records for the

account, which this authorization applicable.)

________________________________________________

Legal Business/Entity Name (As appears on W-9 submitted to

DentaQuest)

________________________________________________

Tax Id (As appears on W-9 submitted to DentaQuest)

ACH Authorization 2


Please attach your VOIDED check here

Legal Business/Entity Name: _______________________________________________

Tax ID Number___________________________________________________________

Documents

DENTAL SERVICE OF MASSACHUSETTS, · PDF file140501 MA SWH MDCR 1 Current Dental Terminology © 2014 American Dental Association. All rights reserved. DENTAL SERVICE OF MASSACHUSETTS,