WSR 16-10-030 EMERGENCY RULES HEALTH CARE AUTHORITY (Washington Apple Health) [Filed April 26, 2016, 1:33 p.m., effective April 26, 2016, 1:33 p.m.] Effective Date of Rule: Immediately upon filing.
Purpose: Emergency rule making was necessary to remove references to billing in thirty minute units from WAC 182-535-1400.
Citation of Existing Rules Affected by this Order: Amending WAC 182-535-1400.
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: Effective January 1, 2016, the American Dental Association/Centers for Medicare and Medicaid Services eliminated the billing code for thirty minute time increments for dental procedures listed in WAC 182-535-1400. The agency became aware of this change in November 2015. Emergency rule making was necessary to implement these changes by January 1, 2016. The agency worked with stakeholders to finalize the language that will be presented at public hearing. The agency is preparing to file the CR-102 and schedule a public hearing in June 2016.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.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: April 26, 2016.
Wendy Barcus
Rules Coordinator
AMENDATORY SECTION (Amending WSR 14-08-032, filed 3/25/14, effective 4/30/14)
WAC 182-535-1400 Payment for dental-related services.
(1) The agency considers that a provider who furnishes covered dental services to an eligible client has accepted the agency's rules and fees.
(2) Participating providers must bill the agency their usual and customary fees.
(3) Payment for dental services is based on the agency's schedule of maximum allowances. Fees listed in the agency's fee schedule are the maximum allowable fees.
(4) The agency pays the provider the lesser of the billed charge (usual and customary fee) or the agency's maximum allowable fee.
(5) The agency pays dental general anesthesia services for eligible clients as follows:
(a) ((The initial thirty minutes constitutes)) Fifteen-minute increments are billed as one unit of time. When a dental procedure ((requiring dental general anesthesia results in)) requires multiple ((time)) fifteen-minute units and there is a remainder (less than fifteen minutes), the remainder ((or fraction)) is considered ((as one time)) one unit.
(b) When billing for anesthesia, the provider must show the actual beginning and ending times in the client's medical record. Anesthesia time begins when the provider starts to physically prepare the client for the induction of anesthesia in the operating room area (or its equivalent), and ends when the provider is no longer in constant attendance (i.e., when the client can be safely placed under postoperative supervision).
(6) The agency pays "by report" on a case-by-case basis, for a covered service that does not have a set fee.
(7) Participating providers must bill a client according to WAC 182-502-0160, unless otherwise specified in this chapter.
(8) If the client's eligibility for dental services ends before the conclusion of the dental treatment, payment for any remaining treatment is the client's responsibility. The exception to this is dentures and partial dentures as described in WAC 182-535-1240 and 182-535-1290.
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