Date of Adoption: September 9, 2003.

     Purpose: To avoid federal penalties, the department is amending these rules to be HIPAA-compliant (P.L. 104-191) by October 16, 2003. Also, to comply with requirements of the 2003-2005 State Omnibus Operating Budget (ESSB 5404), the department is incorporating into rule the 25% reduction in adult dental benefits.

     These rules replace emergency rules filed as WSR 03-16-046.

     Citation of Existing Rules Affected by this Order: Amending WAC 388-535-1240.

     Statutory Authority for Adoption: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.530.

     Other Authority: ESSB 5404 (chapter 25, Laws of 2003, 1st sp.s.), P.L. 104-191.

      Adopted under notice filed as WSR 03-15-129 on July 22, 2003 (Part 3 of 4).

     Changes Other than Editing from Proposed to Adopted Version: The following changes were made in the proposed rules as a result of comments received federal requirements; clarifications; and editorial and typographical corrections. New text is underlined, and deleted text struck through:

     WAC 388-535-1255 (2)(g) Oral prophylaxis treatment, which is: (i) Allowed once every...; and (ii) Not allowed reimbursed when oral prophylaxis treatment is performed on the same date of service as periodontal scaling and root planing, periodontal maintenance, gingivectomy, or gingivoplasty. and(iii) Reimbursed only if periodontal maintenance is not billed for the same client within the same twelve month period.

     WAC 388-535-1255 (2)(h) Restoration of teeth and maintenance of dental health, subject to the limitations in WAC 388-535-1265 and as follows the following: (i) Amalgam and composite restorations are allowed once for the same surface of the same tooth per client, per provider. , subject to the following: (A) (ii) Multiple restorations... (B) (iii) Proximal restorations... (C) (iv) Proximal restorations... (D) (v) MAA pays for a maximum of six surfaces... (E) (vi) MAA pays for a maximum of six surfaces for an anterior tooth... (vii) MAA pays for a core buildup on an anterior or a posterior tooth, including any pins, which is allowed once per client, per provider, in a two-year period, subject to the following: (A) MAA does not pay for a core buildup when a permanent or temporary crown is being placed on the same tooth. (B) MAA does not pay for a core buildup when placed in combination with any other restoration on the same tooth. (F) (viii) MAA pays for flowable composites as a restoration only, when used: (I) Wwith a cavity preparation for a carious lesion that penetrates through the enamel;: (II) (A) As a small Class I (occlusal) restoration; or (III) (B) As a Class V (buccal or lingual) restoration.

     WAC 388-535-1255 (2)(i)(j) Endodontic (root canal)...

     WAC 388-535-1255 (2)(j)(k) Periodontal scaling and root planing, which is: ...(vi) Not allowed when performed on the same date of service as oral prophylaxis, periodontal maintenance, gingivectomy or gingivoplasty. Refer to subsection (2)(g) of this section for limitations on oral prophylaxis. Refer to subsection (2)(k) of this section for limitations on periodontal maintenance.

     WAC 388-535-1255 (2)(k)(l) Periodontal maintenance, which is (i) Allowed... (ii) Allowed ...(iii) Allowed only... (iv) Allowed when... (v) Allowed when... (vi) Allowed when periodontal maintenance starts at least six twelve months after completion of periodontal scaling and root planing or surgical treatment and paid only at six twelve month intervals; and (vii) Not allowed reimbursed when the periodontal maintenance is performed on the same date of services as oral prophylaxis or periodontal scaling and root planing, gingivectomy, or gingivoplasty.; and (viii) Reimbursed only if oral prophylaxis is not billed for the same client within the same twelve-month period.

     WAC 388-535-1255 (2)(l)(m) Dentures and...

     WAC 388-535-1255 (2)(m)(n) Simple extractions...

     WAC 388-535-1255 (2)(n)(o) Surgical extractions...

     WAC 388-535-1255 (2)(o)(p) Medically necessary oral...

     WAC 388-535-1255 (2)(p)(q) Palliative (emergency) treatment of dental pain and infections, minor procedures, which is: (i) Allowed once per client, per day. (ii) Allowed Reimbursed only when performed on a different date from: (A)...; and (B)... (iii) Allowed Reimbursed only when a description of the service…

     WAC 388-535-1255 (2)(q)(r) Behavior management...

     WAC 388-535-1255 (3)(b) One of the following combinations of preventive or periodontal procedures, subject to the limitations listed: (b) (i) Prophylaxis or periodontal maintenance, three times per calendar year; (c) (ii) Periodontal scaling and root planing, once every six months two times per calendar year; or (iii) Prophylaxis or periodontal maintenance, two times per calendar year, and periodontal scaling and root planing, once per calendar year.

     WAC 388-535-1255 (3)(d)(c) Gingivectomy or gingivectoplasty, allowed for four or more contiguous teeth or bounded teeth spaces per quadrant, once every three years.

     WAC 388-535-1255 (3)(h) Limited visual oral assessment (does not replace an oral evaluation) when the assessment includes appropriate referrals, charting of patient data and oral health status and informing the client's parent or guardian of the results, and when at least one of the following occurs: (i) The provision of triage services; (ii) An intraoral screening of soft tissues by a public health dental hygienist to assess the need for prophylaxis, fluoride varnish, or referral for other dental treatments by a dentist, or (iii) In circumstances where the client will be referred to a dentist for treatment, the referring provider will not provide treatment or provide a full evaluation at the time of the assessment.

     WAC 388-535-1255 (5)(d) When the anesthesia is administered by: (i) An oral surgeon who has a current conscious sedation permit or a current general anesthesia permit from DOH; (ii) An anesthesiologist; (iii) A dental anesthesiologist who has a current conscious sedation permit or a current general anesthesia permit from DOH; (iv)...

     WAC 388-535-1255 (7)(a) Dental services must be requested…or a referral for services must be made by the attending physician, the director of nursing, or the nursing facility supervisor;, as appropriate, allowed once per day (not per client and not per facility), per provider; and

     WAC 388-535-1255 (7)(c) A beside call at a nursing facility or group home is allowed once per day (not per client and not per facility), per provider. The bedside call must be requested by the client's physician.

     WAC 388-535-1265 (2)(p) Rebasing or adjustments of complete and immediate dentures and partial dentures.

     WAC 388-535-1265 (2)(q) Adjustments of complete and immediate dentures and partial dentures.

     WAC 388-535-1265 (2)(q)(r) Tooth implants...

     WAC 388-535-1265 (2)(r)(s) Periodontal bone...

     WAC 388-535-1265 (2)(s)(t) Gingivectomy, gingivoplasty, or frenectomy/frenoplasty frenectomy, frenoplasty, and...

     WAC 388-535-1265 (2)(t)(u) ; (u)(v); (v)(w); (w)(x).

     WAC 388-535-1265 (2)(x)(y) Alveoloplasty, alveoloectomy or troi/exostosis tori, exostosis removal.

     WAC 388-535-1265 (2)(y)(z) Debridement of granuloma/cyst granuloma or cyst associated with tooth extraction.

     WAC 388-535-1265(2) Correct lettering in subsections (2)(z) through (2)(kk).

     WAC 388-535-1265(3) MAA evaluates a request for dental-related services that are not covered or are in excess of the dental services program's limitations or restrictions, according to WAC 388-501-0165.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 2, Amended 1, 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 2, Amended 1, Repealed 0.
     Effective Date of Rule: Thirty-one days after filing.

September 9, 2003

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

     (a) An immediate set (constructed prior to removal of the teeth);

     (b) An initial set (constructed after the client has been without teeth for a period of time); or

     (c) A final set (constructed after the client has received immediate or initial dentures).

     (2) The first ((set of dentures)) maxillary denture and the first mandibular denture must be of the structure and quality to be considered the primary set. MAA does not cover transitional or treatment dentures.

     (3) MAA covers partials (resin and cast base) once every five years, except as noted in subsection (4) of this section, and subject to the following limits:

     (a) Cast base partials only when replacing three or more teeth per arch excluding wisdom teeth; and

     (b) No partials are covered when they replace wisdom teeth only.

     (4) Except as stated below, MAA does not require prior authorization for replacement dentures or partials when:

     (a) The client's existing dentures or partials meet any of the following conditions. MAA requires prior authorization for replacement dentures or partials requested within one year of the seat date. The dentures or partials must be:

     (i) No longer serviceable and cannot be relined or rebased; or

     (ii) Damaged beyond repair.

     (b) The client's health would be adversely affected by absence of dentures;

     (c) The client has been able to wear dentures successfully;

     (d) The dentures or partials meet the criteria of medically necessary; and

     (e) The dentures are replacing a lost ((dentures)) maxillary denture and/or a mandibular denture, and the replacement set does not exceed MAA's limit of one set in a ten-year period as stated in subsection (1) of this section.

     (5) MAA does not reimburse separately for laboratory and professional fees for dentures and partials. However, MAA may partially reimburse for these fees when the provider obtains prior authorization and the client:

     (a) Dies;

     (b) Moves from the state;

     (c) Cannot be located; or

     (d) Does not participate in completing the dentures.

     (6) The provider must document in the client's medical or dental record:

     (a) Justification for replacement of dentures;

     (b) Charts of missing teeth, for replacement of partials; and

     (c) Receipts for laboratory costs or laboratory records and notes.

     (7) For billing purposes, the provider may use the impression date as the service date for dentures, including partials, only when:

     (a) Related dental services including laboratory services were provided during a client's eligible period; and

     (b) The client is not eligible at the time of delivery.

     (8) For billing purposes, the provider may use the delivery date as the service date when the client is using the first set of dentures in lieu of noncovered transitional or treatment dentures after oral surgery.

     (9) MAA includes the cost of relines and adjustments that are done within six months of the seat date in the reimbursement for the dentures.

     (10) MAA covers one rebase in a five-year period; the dentures must be at least three years old.

     (11) The requirements in this section also apply to overdentures.

[Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.500, 74.09.520, 42 U.S.C. 1396d(a), 42 C.F.R. 440.100 and 440.225. 02-13-074, § 388-535-1240, 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 1396d(a), CFR 440.100 and 440.225. 99-07-023, § 388-535-1240, filed 3/10/99, effective 4/10/99.]

     (a) Within the scope of an eligible client's medical care program;

     (b) Medically necessary; and

     (c) Within accepted dental or medical practice standards and are:

     (i) Consistent with a diagnosis of dental disease or condition; and

     (ii) Reasonable in amount and duration of care, treatment, or service.

     (2) MAA covers the following dental-related services for eligible adults, subject to the restrictions and limitations in this section and other applicable WAC:

     (a) Medically necessary services for the identification of dental problems or the prevention of dental disease, subject to the limitations of this chapter.

     (b) A comprehensive oral evaluation once per provider as an initial examination, that must include:

     (i) A complete dental and medical history and a general health assessment;

     (ii) A complete thorough evaluation of extra-oral and intra-oral hard and soft tissue; and

     (iii) The evaluation and recording of dental caries, missing or unerupted teeth, restorations, occlusal relationships, periodontal conditions (including periodontal charting), hard and soft tissue anomalies, and oral cancer screening.

     (c) Periodic oral evaluations once every six months to include a periodontal screening/charting at least once per year. There must be six months between the comprehensive oral evaluation and the first periodic oral evaluation.

     (d) Limited oral evaluations only when the provider is not providing pre-scheduled dental services for the client. The limited oral evaluation must be:

     (i) To provide limited or emergent services for a specific dental problem; and/or

     (ii) To provide an evaluation for a referral.

     (e) Radiographs, as follows:

     (i) Intraoral, complete series (including bitewings), allowed only once in a three-year period;

     (ii) Panoramic film, allowed only once in a three-year period and only for oral surgical purposes (see subsection (3) of this section for clients of the division of developmental disabilities);

     (iii) Periapical radiographs as needed (periapical radiographs and bitewings taken on the same date of service cannot exceed MAA's fee for a complete intraoral series); and

     (iv) Bitewings, up to four allowed every twelve months.

     (f) Fluoride treatment as follows (see subsection (3) of this section for clients of the division of developmental disabilities):

     (i) Topical application of fluoride gel or fluoride varnish for adults age nineteen through sixty-four with xerostomia (requires prior authorization); and

     (ii) Topical application of fluoride gel or fluoride varnish for adults age sixty-five and older for:

     (A) Rampant root surface decay; or

     (B) Xerostomia.

     (g) Oral prophylaxis treatment, which is:

     (i) Allowed once every twelve months for adults age nineteen and older, including nursing facility clients, and for clients of the division of developmental disabilities as provided in subsection (3) of this section;

     (ii) Not reimbursed when oral prophylaxis treatment is performed on the same date of service as periodontal scaling and root planing, gingivectomy, or gingivoplasty; and

     (iii) Reimbursed only if periodontal maintenance is not billed for the same client within the same twelve-month period.

     (h) Restoration of teeth and maintenance of dental health, subject to the limitations in WAC 388-535-1265 and the following:

     (i) Amalgam and composite restorations are allowed once for the same surface of the same tooth per client, per provider;

     (ii) Multiple restorations involving the proximal and occlusal surfaces of the same tooth are considered to be a single multisurface restoration. Payment is limited to that of a single multisurface restoration.

     (iii) Proximal restorations that do not involve the incisal angle in the anterior teeth are considered to be a two-surface restoration. Payment is limited to a two-surface restoration.

     (iv) Proximal restorations that involve the incisal angle are considered to be either a three- or four-surface restoration. All surfaces must be listed on the claim for payment.

     (v) MAA pays for a maximum of six surfaces for a posterior tooth, which is allowed once per client, per provider, in a two-year period.

     (vi) MAA pays for a maximum of six surfaces for an anterior tooth, which is allowed once per client, per provider, in a two-year period.

     (vii) MAA pays for a core buildup on an anterior or a posterior tooth, including any pins, which is allowed once per client, per provider, in a two-year period, subject to the following:

     (A) MAA does not pay for a core buildup when a permanent or temporary crown is being placed on the same tooth.

     (B) MAA does not pay for a core buildup when placed in combination with any other restoration on the same tooth.

     (viii) MAA pays for flowable composites as a restoration only, when used with a cavity preparation for a carious lesion that penetrates through the enamel:

     (A) As a small Class I (occlusal) restoration; or

     (B) As a Class V (buccal or lingual) restoration.

     (i) Endodontic (root canal) therapy for permanent anterior teeth only.

     (j) Periodontal scaling and root planing, which is:

     (i) Allowed for clients of the division of developmental disabilities as provided in subsection (3) of this section;

     (ii) Allowed for clients age nineteen and older;

     (iii) Allowed only when the client has radiographic evidence of periodontal disease. There must be supporting documentation in the client's record, including complete periodontal charting and a definitive periodontal diagnosis;

     (iv) Allowed once per quadrant in a twenty-four month period;

     (v) Allowed only when the client's clinical condition meets existing periodontal guidelines; and

     (vi) Not allowed when performed on the same date of service as oral prophylaxis, periodontal maintenance, gingivectomy or gingivoplasty. Refer to subsection (2)(g) of this section for limitations on oral prophylaxis. Refer to subsection (2)(k) of this section for limitations on periodontal maintenance.

     (k) Periodontal maintenance, which is:

     (i) Allowed for clients of the division of developmental disabilities as provided in subsection (3) of this section;

     (ii) Allowed for clients age nineteen and older;

     (iii) Allowed only when the client has been previously treated for periodontal disease, including surgical or nonsurgical periodontal therapy;

     (iv) Allowed when supporting documentation in the client's record includes a definitive periodontal diagnosis and complete periodontal charting;

     (v) Allowed when the client's clinical condition meets existing periodontal guidelines;

     (vi) Allowed when periodontal maintenance starts at least twelve months after completion of periodontal scaling and root planing or surgical treatment and paid only at twelve month intervals;

     (vii) Not reimbursed when the periodontal maintenance is performed on the same date of service as periodontal scaling and root planing, gingivectomy, or gingivoplasty; and

     (viii) Reimbursed only if oral prophylaxis is not billed for the same client within the same twelve-month period.

     (l) Dentures and partial dentures according to WAC 388-535-1290.

     (m) Simple extractions (includes local anesthesia, suturing, and routine postoperative care).

     (n) Surgical extractions, subject to the following:

     (i) Includes local anesthesia, suturing, and routine postoperative care; and

     (ii) Requires documentation in the client's file to support soft tissue, partially bony, or completely bony extractions.

     (o) Medically necessary oral surgery when coordinated with the client's managed care plan (if any).

     (p) Palliative (emergency) treatment of dental pain and infections, minor procedures, which is:

     (i) Allowed once per client, per day.

     (ii) Reimbursed only when performed on a different date from:

     (A) Any other definitive treatment necessary to diagnose the emergency condition; and

     (B) Root canal therapy.

     (iii) Reimbursed only when a description of the service is included in the client's record.

     (q) Behavior management that requires the assistance of one additional dental professional staff for clients of the division of developmental disabilities. See subsection (3) of this section.

     (3) For clients of the division of developmental disabilities, MAA allows services as follows:

     (a) Fluoride application, either varnish or gel, three times per calendar year;

     (b) One of the following combinations of preventive or periodontal procedures, subject to the limitations listed:

     (i) Prophylaxis or periodontal maintenance, three times per calendar year;

     (ii) Periodontal scaling and root planing, two times per calendar year; or

     (iii) Prophylaxis or periodontal maintenance, two times per calendar year, and periodontal scaling and root planing, once per calendar year.

     (c) Gingivectomy or gingivectoplasty, allowed for four or more contiguous teeth or bounded teeth spaces per quadrant, once every three years.

     (d) Nitrous oxide;

     (e) Behavior management that requires the assistance of one additional dental professional staff. A description of behavior management must be documented in the client's record;

     (f) Panoramic radiographs;

     (g) General anesthesia or conscious sedation with parenteral or multiple oral agents when medically necessary for providing treatment; and

     (h) Limited visual oral assessment (does not replace an oral evaluation) when the assessment includes appropriate referrals, charting of patient data and oral health status and informing the client's parent or guardian of the results, and when at least one of the following occurs:

     (i) The provision of triage services;

     (ii) An intraoral screening of soft tissues by a public health dental hygienist to assess the need for prophylaxis, fluoride varnish, or referral for other dental treatments by a dentist; or

     (iii) In circumstances where the client will be referred to a dentist for treatment, the referring provider will not provide treatment or provide a full evaluation at the time of the assessment.

     (4) MAA covers dental services that are medically necessary and provided in a hospital under the direction of a physician or dentist for:

     (a) The care or treatment of teeth, jaws, or structures directly supporting the teeth if the procedure requires hospitalization;

     (b) Short stays when the procedure cannot be done in an office setting. See WAC 388-550-1100(6); and

     (c) A hospital call, including emergency care, allowed one per day, per client, per provider.

     (5) MAA covers general anesthesia and conscious sedation with parenteral or multiple oral agents for medically necessary dental services as follows:

     (a) For treatment of clients who are eligible under the division of developmental disabilities.

     (b) For oral surgery procedures.

     (c) When justification for administering the general anesthesia instead of a lesser type of sedation is clearly documented in the client's record.

     (d) When the anesthesia is administered by:

     (i) An oral surgeon who has a current conscious sedation permit or a current general anesthesia permit from DOH;

     (ii) An anesthesiologist;

     (iii) A dental anesthesiologist who has a current conscious sedation permit or a current general anesthesia permit from DOH;

     (iv) A Certified Registered Nurse Anesthetist (CRNA), if the performing dentist has a current conscious sedation permit or a current general anesthesia permit from the department of health (DOH); or

     (v) A dentist who has a current conscious sedation permit or a current general anesthesia permit from DOH.

     (e) When the provider meets the prevailing standard of care and at least the requirements in WAC 246-817-760, Conscious sedations with parenteral or multiple oral agents and WAC 246-817-770, General anesthesia.

     (6) MAA pays for anesthesia services according to WAC 388-535-1350.

     (7) MAA covers dental-related services for clients residing in nursing facilities or group homes as follows:

     (a) Dental services must be requested by the client or the client's surrogate decision maker as defined in WAC 388-97-055, or a referral for services must be made by the attending physician, the director of nursing, or the nursing facility supervisor, as appropriate, allowed once per day (not per client and not per facility), per provider; and

     (b) Nursing facilities must provide dental-related necessary services according to WAC 388-97-012, Nursing facility care.

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     (2) MAA does not cover the following dental-related services for adults:

     (a) Any service specifically excluded by statute.

     (b) More costly services when less costly, equally effective services as determined by the department are available.

     (c) Services, procedures, treatment, devices, drugs, or application of associated services which the department or the Centers for Medicare and Medicaid Services (CMS) consider investigative or experimental on the date the services were provided.

     (d) Coronal polishing.

     (e) Fluoride treatments (gel or varnish) for adults, unless the clients are:

     (i) Clients of the division of developmental disabilities;

     (ii) Diagnosed with xerostomia, in which case the provider must request prior authorization; or

     (iii) High-risk adults sixty-five and older. High-risk means the client has at least one of the following:

     (A) Rampant root surface decay; or

     (B) Xerostomia.

     (f) Restorations for wear on any surface of any tooth without evidence of decay through the enamel or on the root surface.

     (g) Flowable composites for interproximal or incisal restorations.

     (h) Any permanent crowns, temporary crowns, or crown post and cores.

     (i) Bridges, including abutment teeth and pontics.

     (j) Root canal services for primary teeth.

     (k) Root canal services for permanent teeth other than teeth six, seven, eight, nine, ten, eleven, twenty-two, twenty-three, twenty-four, twenty-five, twenty-six, and twenty-seven.

     (l) Pulpotomy services for permanent teeth.

     (m) Transitional or treatment dentures.

     (n) Overdentures.

     (o) Replacements for:

     (i) Immediate maxillary or mandibular dentures;

     (ii) Maxillary or mandibular partial dentures (resin); or

     (iii) Complete maxillary or mandibular dentures in excess of one replacement in a ten-year period; or

     (iv) Cast metal framework maxillary or mandibular partial dentures in excess of one replacement in a ten-year period.

     (p) Rebasing of complete and immediate dentures and partial dentures.

     (q) Adjustments of complete and immediate dentures and partial dentures.

     (r) Tooth implants, including insertion, post-insertion, maintenance, and implant removal.

     (s) Periodontal bone grafts or oral soft tissue grafts.

     (t) Gingivectomy, gingivoplasty, or frenectomy, frenoplasty and other periodontal surgical procedures.

     (u) Crown lengthening procedures.

     (v) Orthotic appliances, including but not limited to, night guards, tempormandibular joint dysfunction (TMJ/TMD) appliances, and all other mouth guards.

     (w) Any treatment of TMJ/TMD.

     (x) Extraction of:

     (i) Asymptomatic teeth;

     (ii) Asymptomatic wisdom teeth; and

     (iii) Surgical extraction of anterior teeth seven, eight, nine, ten, twenty-three, twenty-four, twenty-five, or twenty-six, which are considered simple extractions and paid as such.

     (y) Alveoloplasty, alveoloectomy or tori, exostosis removal.

     (z) Debridement of granuloma or cyst associated with tooth extraction.

     (aa) Cosmetic treatment or surgery, except as prior authorized by the department for medically necessary reconstructive surgery to correct defects attributable to an accident, birth defect, or illness.

     (bb) Nonemergent oral surgery for adults performed in an inpatient hospital setting, except:

     (i) Nonemergent oral surgery is covered in an inpatient hospital setting for clients of the division of developmental disabilities when written prior authorization is obtained for the inpatient hospitalization; or

     (ii) As provided in WAC 388-535-1080(4).

     (cc) Dental supplies such as toothbrushes (manual, automatic, or electric), toothpaste, floss, or whiteners.

     (dd) Dentist's time writing and calling in prescriptions or prescription refills.

     (ee) Educational supplies.

     (ff) Missed or canceled appointments.

     (gg) Nonmedical equipment, supplies, personal or comfort items or services.

     (hh) Provider mileage or travel costs.

     (ii) Service charges or delinquent payment fees.

     (jj) Supplies used in conjunction with an office visit.

     (kk) Take-home drugs.

     (ll) Teeth whitening.

     (3) MAA evaluates a request for dental-related services that are not covered or are in excess of the dental services program's limitations or restrictions, according to WAC 388-501-0165.

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