PDFWAC 182-535A-0060

Orthodontic treatment and orthodontic-related services—Payment.

(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, not limited to services:
(a) Determined to be below the standard of care; or
(b) Of an unacceptable product quality; or
(c) That are not rendered; or
(d) That do not address medical issue(s) as listed in the prior authorization request.
(5) 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 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).
(c) Continuing follow-up treatment must be billed as periodic orthodontic treatment visits.
(i) Payments are allowed once every three months during treatment.
(ii) Payment for treatment provided in addition to the 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) 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 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).
(c) Continuing follow-up treatment must be billed as periodic orthodontic treatment visits.
(i) Payments are allowed once every three months during treatment with the eighth periodic orthodontic treatment visit covering the last six months of treatment.
(ii) Payment for treatment provided in addition to the 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) 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
(c) Formal case conference.
(8) Payment for orthodontic treatment and orthodontic-related services is based on the agency's published fee schedule.
(9) 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) 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) 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.
(12) 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) See WAC 182-502-0160 and 182-501-0200 for when a provider or a client is responsible to pay for a covered service.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-18-006, § 182-535A-0060, filed 8/18/21, effective 1/1/22; WSR 20-03-042, § 182-535A-0060, filed 1/8/20, effective 2/8/20; WSR 19-11-028, § 182-535A-0060, filed 5/7/19, effective 7/1/19; WSR 17-20-097, § 182-535A-0060, filed 10/3/17, effective 11/3/17; WSR 16-10-064, § 182-535A-0060, filed 5/2/16, effective 6/2/16. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535A-0060, filed 3/25/14, effective 4/30/14. WSR 11-14-075, recodified as § 182-535A-0060, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 08-17-009, § 388-535A-0060, filed 8/7/08, effective 9/7/08. Statutory Authority: RCW 74.08.090, 74.09.520 and 74.09.035, 74.09.500. WSR 05-01-064, § 388-535A-0060, filed 12/8/04, effective 1/8/05. 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. WSR 02-01-050, § 388-535A-0060, filed 12/11/01, effective 1/11/02.]