((Coverage and authorization of covered services is subject to the requirements and limitations in this chapter and other applicable WAC.))Orthodontic treatment and orthodontic-related services require prior authorization.

(1) The medicaid agency covers orthodontic treatment and orthodontic-related services for a client who has one of the medical conditions listed in (a) and (b) of this subsection. Treatment and follow-up care must be performed only by an orthodontist or agency-recognized craniofacial team.

(a) Cleft lip and palate, cleft palate, or cleft lip with alveolar process involvement.

(b) The following craniofacial anomalies including, but not limited to:

(i) Hemifacial microsomia;

(ii) Craniosynostosis syndromes;

(iii) Cleidocranial dental dysplasia;

(iv) Arthrogryposis;

(v) Marfan syndrome;

(vi) Treacher Collins syndrome;

(vii) Ectodermal dysplasia; or

(viii) Achondroplasia.

(2) The agency authorizes orthodontic treatment and orthodontic-related services when the following criteria are met:

(a) Severe malocclusions with a Washington Modified Handicapping Labiolingual Deviation (HLD) Index Score of twenty-five or higher as determined by the agency;

(b) The client has established caries control; and

(3) The agency ((may)) covers orthodontic treatment for dental malocclusions other than those listed in subsections (1) and (2) of this section on a case-by-case basis ((and)) when ((prior authorized.))the agency determines medical necessity based on documentation submitted by the provider.

(4) The agency does not cover the following orthodontic treatment or orthodontic-related services:

(a) Orthodontic treatment for cosmetic purposes;

(b) Orthodontic treatment that is not medically necessary (((as defined in WAC 182-500-0070)));

(c) Orthodontic treatment provided out-of-state, except as stated in WAC 182-501-0180 (see also WAC 182-501-0175 for medical care provided in bordering cities); or

(d) Orthodontic treatment and orthodontic-related services that do not meet the requirements of this section or other applicable WAC((; or

(e) Case studies that do not include a definitive orthodontic treatment plan)).

(5) The agency covers the following orthodontic treatment and orthodontic-related services ((with prior authorization when medically necessary)):

(a) Interceptive orthodontic treatment.

(b) Limited orthodontic treatment. ((The agency may approve limited orthodontic treatment for treatment of a single impacted tooth.))

(c) Comprehensive full orthodontic treatment on adolescent dentition (((see subsection (8)(a) of this section for information on limitation extensions))).

(d) A case study when done in conjunction with interceptive, limited, or comprehensive orthodontic treatment only.

(e) Other orthodontic treatment subject to review for medical necessity as determined by the agency.

(6) The agency covers the following orthodontic-related services ((with prior authorization when medically necessary)):

(a) Clinical oral evaluations according to WAC 182-535-1080.

(b) Cephalometric films that are of diagnostic quality, dated, and labeled with the client's name.

(d))) Orthodontic appliance removal as a stand-alone service only when:

(i) The client's appliance was placed by a different provider or dental clinic; and

(ii) The provider has not furnished any other orthodontic treatment or orthodontic-related services to the client.

(7) The treatment must meet industry standards and correct the medical issue. If treatment is discontinued prior to completion, or treatment objectives are not achieved, the provider must:

(a) ((Keep clear documentation))Document in the client's record ((explaining)) why treatment was discontinued or not completed, or why treatment goals were not achieved.

(b) Notify the agency by submitting the Orthodontic Discontinuation of Service form (HCA 13-0039).

(8) The agency evaluates a request for orthodontic treatment or orthodontic-related services:

(a) That are in excess of the limitations or restrictions listed in this section, according to WAC 182-501-0169; and

(b) That are listed as noncovered according to WAC 182-501-0160.

(9) The agency reviews requests for orthodontic treatment or orthodontic-related services for clients who are eligible for services under the EPSDT program according to the provisions of WAC 182-534-0100.

(((1))) When the medicaid agency authorizes an interceptive orthodontic treatment, limited orthodontic treatment, full orthodontic treatment, or orthodontic-related services for a client, including a client eligible for services under the EPSDT program, that authorization indicates only that the specific service is medically necessary; authorization is not a guarantee of payment. The client must be eligible for the covered service at the time the service is provided.

(((2) For orthodontic treatment of a client with cleft lip, cleft palate, or other craniofacial anomaly, prior authorization is not required if the client is being treated by an agency-recognized craniofacial team, or an orthodontic specialist who has been approved by the agency to treat cleft lip, cleft palate, or other craniofacial anomalies.

(3) Subject to the conditions and limitations of this section and other applicable WAC, the agency requires prior authorization for orthodontic treatment and/or orthodontic-related services for other dental malocclusions that are not listed in WAC 182-535A-0040(1).))

(1) The medicaid agency pays providers for furnishing covered orthodontic treatment and orthodontic-related services described in WAC 182-535A-0040 according to this section and other applicable WAC.

(2) A provider who furnishes covered orthodontic treatment and orthodontic-related services to an eligible client accepts the agency's fees as published in the agency's fee schedules according to WAC 182-502-0010.

(3) Providers must deliver services and procedures that are of acceptable quality to the agency.

(4) The agency may recoup payment ((for)), not limited to services:

(a) Determined to be below the standard of care; or

(b) Of an unacceptable product quality; or

(((4)))(5)Interceptive orthodontic treatment. The agency pays for interceptive orthodontic treatment on primary or transitional dentition in one payment that includes all professional fees, laboratory costs, and required follow-up.

(((5)))(6)Limited orthodontic treatment. The agency pays for limited orthodontic treatment on transitional or adolescent dentition as follows:

(a) The first three months of treatment starts on the date the initial appliance is placed and includes active treatment for the first three months. The provider must bill the agency with the date of service that the initial appliance is placed.

(b) The agency's initial payment includes:

(i) The ((replacement of brackets and lost or broken))placement of orthodontic appliances;

(ii) Appliance removal;

(iii) The initial retainer fee; and

(iv) The final records (photos, a panoramic X-ray, a cephalometric film, and final trimmed study models).

(i) Payments are allowed once every ((six weeks))three months during treatment((, beginning three months after the initial appliance placement)).

(ii) Payment for treatment provided in addition to the ((six))three periodic orthodontic treatment visits requires a limitation extension. See WAC 182-535A-0040(8).

(iii) If treatment is discontinued or treatment objectives are not achieved, providers must notify the agency. See WAC 182-535A-0040(7).

(((6)))(7)Comprehensive full orthodontic treatment. The agency pays for comprehensive full orthodontic treatment on adolescent dentition as follows:

(a) The first three months of treatment starts the date the initial appliance is placed and includes active treatment for the first three months. The provider must bill the agency with the date of service that the initial appliance is placed.

(b) The agency's initial payment includes:

(i) The ((replacement of brackets and lost or broken))placement of orthodontic appliances;

(ii) Appliance removal;

(iii) The initial retainer fee; and

(iv) The final records (photos, a panoramic X-ray, a cephalometric film, and final trimmed study models).

(i) Payments are allowed once every ((six weeks))three months during treatment((, beginning three months after the initial appliance placement)).

(ii) Payment for treatment provided in addition to the ((fourteen))eight periodic orthodontic treatment visits requires a limitation extension. See WAC 182-535A-0040(8).

(iii) If treatment is discontinued or treatment objectives are not achieved, providers must notify the agency. See WAC 182-535A-0040(7).

(((7)))(8)Case study. The agency pays for a case study, which includes:

(a) Preparation of comprehensive diagnostic records (additional photos, study casts, cephalometric examination film and panoramic film);

(b) Formation of diagnosis and treatment plan from such records; and

(((8)))(9) Payment for orthodontic treatment and orthodontic-related services is based on the agency's published fee schedule.

(((9)))(10) Orthodontic providers who are in agency-designated bordering cities 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 the agency.

(((10)))(11) If the client's eligibility for orthodontic treatment under WAC 182-535A-0020 ends before the conclusion of the orthodontic treatment, payment for any remaining treatment is the client's responsibility. The agency does not pay for these services.

(((11)))(12) The agency does not pay for orthodontic treatment provided after the client's twenty-first birthday. Payment for treatment that continues after the client's twenty-first birthday is the client's responsibility ((of the client)).

(((12)))(13) The client is responsible for payment of any orthodontic service or treatment received during any period of medicaid ineligibility, even if the treatment was started when the client was eligible.

(((13)))(14) See WAC 182-502-0160 and 182-501-0200 for when a provider or a client is responsible to pay for a covered service.