WSR 04-12-041

EMERGENCY RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed May 28, 2004, 8:28 a.m. , effective June 1, 2004 ]


Date of Adoption: May 20, 2004.

Purpose: To comply with federal Public Law 104-191 (Health Insurance Portability and Accountability Act (HIPAA) of 1996), which mandates HIPAA changes be effective no later than October 16, 2003. This rule-making order extends the emergency rule that has been in effect since October 8, 2003. The two previous emergency orders were adopted under WSR 04-04-073 and 03-21-038.

A CR-101 notice was filed September 30, 2003, under WSR 03-20-103, and MAA is actively undertaking the appropriate steps to complete the permanent rule adoption process.

Citation of Existing Rules Affected by this Order: Amending WAC 388-535A-0050 and 388-535A-0060.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.530.

Other Authority: Public Law 104-191 (Health Insurance Portability and Accountability Act of 1996).

Under RCW 34.05.350 the agency for good cause finds that state or federal law or federal rule or a federal deadline for state receipt of federal funds requires immediate adoption of a rule.

Reasons for this Finding: This emergency rule is needed to continue to meet the requirements of the federal Health Insurance Portability and Accountability Act of 1996 while the department completes the permanent rule-making process.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 1, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.

May 20, 2004

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

3316.1
AMENDATORY SECTION(Amending WSR 02-01-050, filed 12/11/01, effective 1/11/02)

WAC 388-535A-0050   Authorization((,)) and prior authorization((, and expedited prior authorization)) for orthodontic services.   (1) When MAA authorizes a service, that authorization indicates only that the specific service is medically necessary; it is not a guarantee of payment. The client must be eligible for the covered service at the time the service is provided.

(2) MAA does not require prior authorization for orthodontic treatment of a client with cleft lip, cleft palate, or craniofacial anomaly when the client is:

(a) Eligible under WAC 388-535A-0020; and

(b) Being treated by a department-recognized cleft palate or craniofacial team.

(3) MAA requires prior authorization for orthodontic treatment of:

(a) Severe handicapping malocclusions;

(b) Dental malocclusions that result in severe dental functional impairment;

(c) Those cases that result in a score less than thirty on the Washington Modified HLD Index Scale; and

(d) Services provided per WAC 388-535A-0030.

(((4) MAA allows orthodontists to use expedited prior authorization (EPA) for those cases that score thirty or more on the Washington Modified HLD Index Scale. The EPA process is designed to eliminate the need for telephone prior authorization for selected procedures. The orthodontist must create an authorization number using the process explained in MAA's orthodontic billing instructions. When MAA finds that a provider is using EPA inappropriately, MAA may:

(a) Require the provider to obtain prior authorization from MAA before providing services to any client; or

(b) Take one or more of the actions in WAC 388-502-0230(3).))

[Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520, 74.09.500, 42 U.S.C. 1396d(a), C.F.R. 440.100 and 225. 02-01-050, 388-535A-0050, filed 12/11/01, effective 1/11/02.]


AMENDATORY SECTION(Amending WSR 02-01-050, filed 12/11/01, effective 1/11/02)

WAC 388-535A-0060   Reimbursement for orthodontic services.   (1) MAA considers that a provider who furnishes covered orthodontic services to an eligible client has accepted MAA's rates and fees.

(2) Payment for orthodontic services is based on MAA's schedule of maximum allowances; fees listed in the fee schedule are the maximum allowable fees.

(3) ((MAA uses state-assigned procedure codes to identify covered orthodontic services.

(4))) MAA does not cover out-of-state orthodontic treatment.

(((5))) (4) Orthodontic providers who are in department-designated border areas must:

(a) Meet the licensure requirements of their state; and

(b) Meet the same criteria for payment as in-state providers, including the requirements to contract with MAA.

(((6))) (5) MAA reimburses for interceptive orthodontic treatment for cleft palate or craniofacial anomaly per WAC 388-535A-0050.

(((7))) (6) With the exception of the conditions listed in subsection (((6))) (5) of this section, MAA reimburses for interceptive orthodontic treatment once per client's lifetime for clients with severe handicapping malocclusions.

(((8))) (7) MAA reimburses for limited transitional orthodontic treatment for a maximum of one year from original appliance placement. Follow up treatment is allowed in three-month increments, beginning three months after the initial placement.

(((9))) (8) MAA reimburses for comprehensive full orthodontic treatment up to a maximum of two years from original appliance placement. Six follow up treatments are allowed in three-month increments, beginning six months after the initial placement.

(((10))) (9) If the client's eligibility for orthodontic treatment under WAC 388-535A-0020 ends before the conclusion of the orthodontic treatment, payment for any remaining treatment is the individual's responsibility; MAA does not reimburse for these services.

(((11))) (10) The client is responsible for payment of any orthodontic service or treatment received during any period of ineligibility, even if the treatment was started when the client was eligible; MAA does not reimburse for these services.

(((12))) (11) The client is responsible for paying for services when the client has not disclosed coverage to the provider, per WAC 388-502-0160 and 388-501-0200; MAA does not reimburse in these situations.

[Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520, 74.09.500, 42 U.S.C. 1396d(a), C.F.R. 440.100 and 225. 02-01-050, 388-535A-0060, filed 12/11/01, effective 1/11/02.]

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