Purpose: The rule establishes standards of coverage for billing codes to ensure the protection of the health and safety of medical assistance clients by restricting billable services to dentists who are entitled to a specialty designation under WAC 246-817-420 and who meet MAA's certification requirements to perform oral and maxillofacial surgery.

     Citation of Existing Rules Affected by this Order: Amending WAC 388-535-1070.

     Statutory Authority for Adoption: RCW 74.08.090, 74.09.500, 74.09.520.

      Adopted under notice filed as WSR 05-03-080 on January 17, 2005.

     A final cost-benefit analysis is available by contacting Dr. John Davis, P.O. Box 45506, Olympia, WA 98504-5506, phone (360) 725-1748, fax (360) 568-1590, e-mail davisjs@dshs.wa.gov. No changes were made. The preliminary analysis will be final.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.

     Date Adopted: February 25, 2005.

Andy Fernando, Manager

Rules and Policies Assistance Unit

     (a) Persons currently licensed by the state of Washington to:

     (i) Practice dentistry or specialties of dentistry.

     (ii) Practice as dental hygienists.

     (iii) Practice as denturists.

     (iv) Practice anesthesia by:

     (A) Providing conscious sedation with ((parental)) parenteral or multiple oral agents, deep sedation, or general anesthesia as an anesthesiologist or dental anesthesiologist;

     (B) Providing conscious sedation with ((parental)) parenteral or multiple oral agents, deep sedation, or general anesthesia as a certified registered nurse anesthetist (CRNA)((, when the performing dentist has the appropriate conscious sedation permit or general anesthesia permit from the department of health (DOH))) under WAC 246-817-180; or

     (C) Providing conscious sedation with parenteral or multiple oral agents((, deep sedation, or general anesthesia)) as a dentist, when the dentist has a conscious sedation permit ((or general anesthesia permit from DOH)) issued by the department of health (DOH) that is current at the time the billed service(s) is provided; or

     (D) Providing deep sedation or general anesthesia as a dentist when the dentist has a general anesthesia permit issued by DOH that is current at the time the billed service(s) is provided.

     (v) Practice medicine and osteopathy for:

     (A) Oral surgery procedures; or

     (B) Providing fluoride varnish under EPSDT.

     (b) Facilities that are:

     (i) Hospitals currently licensed by the ((department of health)) DOH;

     (ii) Federally-qualified health centers (FQHCs);

     (iii) Medicare-certified ambulatory surgical centers (ASCs);

     (iv) Medicare-certified rural health clinics (RHCs); or

     (v) Community health centers.

     (c) Participating local health jurisdictions.

     (d) ((Border area)) Bordering city or out-of-state providers of dental-related services who are qualified in their states to provide these services.

     (2) Subject to the restrictions and limitations in this section and other applicable WAC, MAA pays licensed providers participating in the MAA dental program for only those services that are within their scope of practice.

     (3) For the dental specialty of oral and maxillofacial surgery:

     (a) MAA requires a dentist to:

     (i) Be currently entitled to such specialty designation (to perform oral and maxillofacial surgery) under WAC 246-817-420; and

     (ii) Meet the following requirements in order to be reimbursed for oral and maxillofacial surgery:

     (A) The dentist must have participated at least three years in a maxillofacial residency program; and

     (B) The dentist must be board certified or designated as "board eligible" by the American Board of Oral and Maxillofacial Surgery.

     (b) A dental provider who meets the requirements in (3)(a) of this section must bill claims using appropriate current dental terminology (CDT) codes or current procedural terminology (CPT) codes for services that are identified as covered in WAC and MAA's published billing instructions or numbered memoranda.

     (4) See WAC 388-502-0020 for provider documentation and record retention requirements. MAA requires additional dental documentation under specific sections in this chapter and as required by chapter 246-817 WAC.

     (((4))) (5) See WAC 388-502-0100 and 388-502-0150 for provider billing and payment requirements. Enrolled dental providers who do not meet the conditions in (3)(a) of this section must bill all claims using only the CDT codes for services that are identified in WAC and MAA's published billing instructions or numbered memoranda. MAA does not reimburse for billed CPT codes when the dental provider does not meet the requirements in subsection (3)(a) of this section.

     (((5))) (6) See WAC 388-502-0160 for regulations concerning charges billed to clients.

     (((6))) (7) See WAC 388-502-0230 for provider review and appeal.

     (((7))) (8) See WAC 388-502-0240 for provider audits and the audit appeal process.

[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. 03-19-077, § 388-535-1070, 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. 1396d(a), 42 C.F.R. 440.100 and 440.225. 02-13-074, § 388-535-1070, filed 6/14/02, effective 7/15/02.]

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