PDFWAC 182-535-1220

Obtaining prior authorization for dental-related services.

(1) The medicaid agency uses the determination process for payment described in WAC 182-501-0165 for covered dental-related services that require prior authorization.
(2) The agency requires a dental provider who is requesting prior authorization to submit sufficient, current (within the past twelve months), objective clinical information to establish medical necessity. The request must be submitted in writing on the General Information for Authorization (HCA 13-835) form, available on the agency's website.
(3) The agency may request additional information as follows:
(a) Additional radiographs (X-rays) (refer to WAC 182-535-1080(2));
(b) Photographs; and
(c) Any other information as determined by the agency.
(4) The agency may require second opinions and/or consultations by a licensed independent doctor of dental surgery (DDS)/doctor of medicine in dentistry (DMD) before authorizing any procedure.
(5) When the agency authorizes a dental-related service for a client, that authorization indicates only that the specific service is medically necessary; it is not a guarantee of payment. The authorization is valid for six to twelve months as indicated in the agency's authorization letter and only if the client is eligible for covered services on the date of service.
(6) The agency denies a request for a dental-related service when the requested service:
(a) Is covered by another state agency program;
(b) Is covered by an entity outside the agency; or
(c) Fails to meet the program criteria, limitations, or restrictions in this chapter.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-14-055, § 182-535-1220, filed 7/1/21, effective 8/1/21; WSR 17-20-097, § 182-535-1220, filed 10/3/17, effective 11/3/17; WSR 16-18-033, § 182-535-1220, filed 8/26/16, effective 9/26/16. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535-1220, filed 3/25/14, effective 4/30/14. Statutory Authority: RCW 41.05.021. WSR 12-09-081, § 182-535-1220, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-535-1220, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. WSR 07-06-042, § 388-535-1220, filed 3/1/07, effective 4/1/07. 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. WSR 03-19-078, § 388-535-1220, 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. WSR 02-13-074, § 388-535-1220, 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 U.S.C. 1396d(a), C.F.R. 440.100 and 440.225. WSR 99-07-023, § 388-535-1220, filed 3/10/99, effective 4/10/99.]