Wash. Admin. Code § 182-535-1220

Current through Register Vol. 24-23, December 1, 2024

Section 182-535-1220 - Obtaining prior authorization for dental-related services

(1) The medicaid agency uses the determination process for payment described in WAC 182-501-0165 for covered dental-related services that require prior authorization.

(2) The agency requires a dental provider who is requesting prior authorization to submit sufficient, current (within the past twelve months), objective clinical information to establish medical necessity. The request must be submitted in writing on the General Information for Authorization (HCA 13-835) form, available on the agency's website.

(3) The agency may request additional information as follows:

(a) Additional radiographs (X-rays) (refer to WAC 182535-1080(2));

(b) Photographs; and

(c) Any other information as determined by the agency.

(4) The agency may require second opinions and/or consultations by a licensed independent doctor of dental surgery (DDS)/doctor of medicine in dentistry (DMD) before authorizing any procedure.

(5) When the agency authorizes a dental-related service for a client, that authorization indicates only that the specific service is medically necessary; it is not a guarantee of payment. The authorization is valid for six to twelve months as indicated in the agency's authorization letter and only if the client is eligible for covered services on the date of service.

(6) The agency denies a request for a dental-related service when the requested service:

(a) Is covered by another state agency program;

(b) Is covered by an entity outside the agency; or

(c) Fails to meet the program criteria, limitations, or restrictions in this chapter.

Wash. Admin. Code § 182-535-1220

Amended by WSR 14-08-032, filed 3/25/14, effective 4/30/2014

Amended by WSR 16-18-033, Filed 8/26/2016, effective 9/26/2016

Amended by WSR 17-20-097, Filed 10/3/2017, effective 11/3/2017

Amended by WSR 21-14-055, Filed 7/1/2021, effective 8/1/2021

Statutory Authority: RCW 41.05.021. 12-09-081, §182-535-1220, filed 4/17/12, effective 5/18/12. 11-14-075, recodified as §182-535-1220, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. 07-06-042, § 388-535-1220, filed 3/1/07, effective 4/1/07. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 2003 1st sp.s. c 25, P.L. 104-191. 03-19-078, § 388-535-1220, filed 9/12/03, effective 10/13/03. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.500, 74.09.520, 42 U.S.C. 1396 d(a), 42 C.F.R. 440.100 and 440.225. 02-13-074, § 388-535-1220, filed 6/14/02, effective 7/15/02. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 USC 1396 d(a), C.F.R. 440.100 and 440.225. 99-07-023, § 388-535-1220, filed 3/10/99, effective 4/10/99.