Date of Adoption: June 12, 2002.

     Purpose: Chapter 388-535 WAC, Dental-related services. To clarify and update existing policy, including: Updating (and deleting where necessary) definitions; clarifying provider requirements and adding cross-references to other provider information; clarifying services that are covered and not covered; clarifying policy regarding dentures (including replacements for lost dentures), partials, and laboratory fees; and reorganize and rewrite sections within the chapter to improve readability and understanding to meet the requirements of Executive Order 97-02.

     Citation of Existing Rules Affected by this Order: Repealing WAC 388-535-1010, 388-535-1150, and 388-535-1260; and amending WAC 388-535-1050, 388-535-1060, 388-535-1080, 388-535-1100, 388-535-1200, 388-535-1220, 388-535-1230, 388-535-1240, 388-535-1350, 388-535-1400, 388-535-1450, 388-535-1500, and 388-535-1550.

     Statutory Authority for Adoption: 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.

      Adopted under notice filed as WSR 02-08-088 on April 3, 2002.

     Changes Other than Editing from Proposed to Adopted Version: (a) WAC 388-535-1060 (1)(f), after "Children's health (the state-only funded program)," added, "through September 30, 2002 only;."

     (b) WAC 388-535-1070 (1)(a)(v), after "Practice," replaced "anesthesiology" with, "anesthesia;."

     Changes were made as a result of stakeholder input.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 2, Amended 13, Repealed 3.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 2, Amended 13, Repealed 3.
     Effective Date of Rule: Thirty-one days after filing.

June 12, 2002

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

     "Access to baby and child dentistry (ABCD)" is a ((demonstration project)) program to increase access to dental services in targeted areas for Medicaid eligible infants, toddlers, and preschoolers up through the age of five. See WAC 388-535-1300 for specific information.

     "Adult" for the general purposes of the medical assistance administration's (MAA) dental program, means a client ((nineteen)) twenty-one years of age or older (MAA's payment structure changes at age nineteen, which affects specific program services provided to adults or children).

     "Anterior" means teeth in the front of the mouth. ((In relation to crowns, only these permanent teeth are considered anterior for laboratory processed crowns:))

     (1) "Lower anterior," teeth twenty-two, twenty-three, twenty-four, twenty-five, twenty-six, and twenty-seven; and

     (2) "Upper anterior," teeth six, seven, eight, nine, ten, and eleven.

     (("Arch" means the curving structure formed by the crowns of the teeth in their normal position, or by the residual ridge after loss of the teeth.))

     "Asymptomatic" means having or producing no symptoms.

     (("Banding" means the application of orthodontic brackets to the teeth for the purpose of correcting dentofacial abnormalities.))

     "Base metal" means dental alloy containing little or no precious metals.

     "Behavior management" means managing the behavior of a client during treatment using the assistance of additional professional staff, and professionally accepted restraints or sedative agent, to protect the client from self-injury.

     (("Bicuspid" means teeth four, five, twelve, thirteen, twenty, twenty-one, twenty-eight, and twenty-nine.))

     "By report" - a method of payment for a covered service, supply, or equipment which:

     (1) Has no maximum allowable established by MAA,

     (2) Is a variation on a standard practice, or

     (3) Is rarely provided.

     "Caries" means tooth decay through the enamel.

     "Child" for the general purposes of the medical assistance administration's (MAA) dental program, means a client ((eighteen)) twenty years of age or younger. (MAA's payment structure changes at age nineteen, which affects specific program services provided to children or adults.)

     (("Cleft" means an opening or fissure involving significant dental processes, especially one occurring in the embryo. These can be:

     (1) Cleft lip,

     (2) Cleft palate (at the roof of the mouth), or

     (3) Transverse facial cleft (macrostomia).))

     "Comprehensive oral evaluation" means a thorough evaluation and recording of the hard and soft tissues in and around the mouth, including the evaluation and recording of the ((patient's)) client's dental and medical history and a general health assessment.

     (("Corona")) "Coronal" is the portion of a tooth that is covered by enamel, and is separated from the root or roots by a slightly constricted region, known as the cemento-enamel junction.

     (("Craniofacial anomalies" means abnormalities of the head and face, either congenital or acquired, involving significant dental processes.

     "Craniofacial team" means a department of health and MAA recognized cleft palate/maxillofacial team which is: Responsible for management (review, evaluation, and approval) of patients with cleft palate craniofacial anomalies to provide integrated case management, promote parent-professional partnership, making appropriate referrals to implement and coordinate treatment plans.))

     "Crown (artificial)" means a restoration covering or replacing the major part, or the whole of, the clinical crown of a tooth.

     "Current dental terminology (CDT), ((second)) third edition (((CDT-2)) CDT-3)," a systematic listing of descriptive terms and identifying codes for reporting dental services and procedures performed by dental practitioners. CDT is published by the Council on Dental Benefit Programs of the American Dental Association (ADA).

     "Current procedural terminology 2002 (CPT 2002)," means a description of medical procedures and is available from the American Medical Association of Chicago, Illinois.

     "Dental general anesthesia" means the use of agents to induce loss of feeling or sensation, a controlled state of unconsciousness, in order to allow dental services to be rendered to the client.

     (("Dentally necessary" means diagnostic, preventive, or corrective services that are accepted dental procedures appropriate for the age and development of the client to prevent the incidence or worsening of conditions that endanger teeth or periodontium (tissues around the teeth) or cause significant malfunction or impede reasonable development or homeostatis (health) in the stomatognathic (mouth and jaw) system:

     (1) Which may include simple observation with no treatment, if appropriate; and

     (2) Includes use of less costly, equally effective services.

     "Dentin" is the mineralized tissue of the teeth, which surrounds the tooth pulp and is covered by enamel on the crown and by cementum on the roots of the teeth.))

     "Dentures" are a set of ((prosthetic)) artificial teeth, including overdentures. See WAC 388-535-1240 for specific information.

     (("Dysplasia" means an abnormality in the development of the teeth.

     "Enamel" is the white, compact, and very hard substance that covers and protects the dentin of the crown of a tooth.))

     "Endodontic" means a root canal treatment and related follow-up.

     "EPSDT((/healthy kids))" means the department's early and periodic screening, diagnosis, and treatment program for clients twenty years of age and younger as described in chapter 388-534 WAC.

     "Fluoride varnish or gel" means a substance containing dental fluoride, ((for painting onto)) applied to teeth. ((When painted onto teeth, it sticks to tooth surfaces.

     "Gingiva" means the gums.

     "Hemifacial microsomia" means half or part of the face is smaller-sized.

     "High noble metal" means dental alloy containing at least sixty percent pure gold.

     "High risk child" means any child who has been identified through an oral evaluation or assessment as being at a high risk for developing dental disease because of caries in the child's dentin; or a child identified by the department as developmentally disabled.

     "Hypoplasia" means the incomplete or defective development of the enamel of the teeth.

     "Low risk child" means any child who has been identified through an oral evaluation or assessment as being at a low risk for dental disease because of the absence of white spots or caries in the enamel or dentin. This category includes children with restorations who are otherwise without disease.))

     "Limited oral evaluation" means an evaluation limited to a specific oral health condition or problem.

     "Major bone grafts" means a transplant of solid bone tissue(s)((, such as buttons or plugs.

     "Malocclusion" means the contact between the upper and lower teeth that interferes with the highest efficiency during the movements of the jaw that are essential to chewing. The abnormality is categorized into four classes, graded by Angle's classification. For coverage, see WAC 388-535-1250.

     "Maxillofacial" means relating to the jaws and face.))

     "Medically necessary" see WAC 388-500-0005.

     "Minor bone grafts" means a transplant of nonsolid bone tissue(s), such as powdered bone, buttons, or plugs.

     (("Moderate risk child" means a child who has been identified through an oral evaluation or assessment as being at a moderate risk for dental disease, based on presence of white spots, enamel caries or hypoplasia.

     "Molars" means:

     (1) Permanent teeth one, two, three, fourteen, fifteen, sixteen, seventeen, eighteen, nineteen, thirty, thirty-one, and thirty-two; and

     (2) Primary teeth A, B, I, J, K, L, S and T.))

     "Noble metal" means a dental alloy containing at least twenty-five percent but less than sixty percent pure gold.

     (("Occlusion" means the relation of the upper and lower teeth when in functional contact during jaw movement.))

     "Oral evaluation" is a comprehensive oral health and developmental history; an assessment of physical and oral health development and nutritional status; and health education, including anticipatory guidance.

     "Oral health assessment or screening" means a screening of the hard and soft tissues in the mouth.

     "Oral hygiene instruction" means instruction for home oral hygiene care, such as tooth brushing techniques or flossing.

     "Oral health status" refers to the client's risk or susceptibility to dental disease at the time an oral evaluation or assessment is done by a dental practitioner. This risk is designated as low, moderate or high based on the presence or absence of certain indicators.

     (("Orthodontic" is a treatment involving the use of any appliance, in or out of the mouth, removable or fixed, or any surgical procedure designed to redirect teeth and surrounding tissues.))

     "Partials" or "partial dentures" means a ((prosthetic)) removable appliance replacing one or more missing teeth in one jaw, and receiving its support and retention from both the underlying tissues and some or all of the remaining teeth. See WAC 388-535-1240 for specific information.

     "Posterior" means teeth and tissue towards the back of the mouth. Specifically, only these permanent teeth: One, two, three, four, five, twelve, thirteen, fourteen, fifteen, sixteen, seventeen, eighteen, nineteen, twenty, twenty-one, twenty-eight, twenty-nine, thirty, thirty-one, and thirty-two.

     (("Prophylaxis" means intervention which includes the scaling and polishing of teeth to remove coronal plaque, calculus, and stains.))

     "Reline" means to resurface the tissue side of a denture with new base material in order to achieve a more accurate fit.

     "Root planing" is a procedure designed to remove microbial flora, bacterial toxins, calculus, and diseased cementum or dentin from the teeth's root surfaces and pockets.

     "Scaling" means the removal of calculous material from the exposed tooth surfaces and that part of the teeth covered by the marginal gingiva.

     "Sealant" is a material applied to teeth to prevent dental caries.

     (("Sequestrectomy" means removal of dead or dying bone that has separated from healthy bone.))

     "Symptomatic" means having symptoms (e.g., pain, swelling, and infection).

     "Therapeutic pulpotomy" means the surgical removal of a portion of the pulp (inner soft tissue of a tooth), to retain the healthy remaining pulp.

     "Usual and customary" means the fee that the provider usually charges non-Medicaid customers for the same service or item. This is the maximum amount that the provider may bill MAA.

     "Wisdom teeth" means teeth one, sixteen, seventeen, and thirty-two.

     "Xerostomia" means a dryness of the mouth.

[Statutory Authority: RCW 74.08.090. 01-02-076, § 388-535-1050, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 USC 1396d(a), CFR 440.100 and 440.225. 99-07-023, § 388-535-1050, filed 3/10/99, effective 4/10/99. Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090. 96-01-006 (Order 3931), § 388-535-1050, filed 12/6/95, effective 1/6/96.]

     (a) Categorically needy program (CN or CNP)((, including:

     (i) Children's health; and

     (ii) Pregnant undocumented aliens.

     (b) Medically needy (MN)));

     (b) Children's health insurance program (CNP-CHIP);

     (c) Qualified Medicare beneficiary (CNP-QMB);

     (d) Limited casualty program/medically needy program (LCP-MNP);

     (e) Medically needy program - qualified Medicare beneficiary (MNP-QMB);

     (f) Children's health (the state-funded only program) through September 30, 2002 only; and

     (g) Pregnant undocumented aliens.

     (2) Clients ((with)) who receive services under the following state-((only)) funded ((eligibility)) only programs ((receive the coverage)) are covered as described in WAC ((388-535-1260)) 388-535-1120:

     (a) General assistance unemployable (GAU); and

     (b) Alcohol and drug abuse treatment and support act (ADATSA).

     (3) Clients ((of)) who receive services under the medically indigent (MI) program are ((limited to emergency hospital-based services only)) covered for only those medical conditions that are acute and emergent and treated in a hospital.

     (4) Clients who are enrolled in a managed care plan are eligible for medical assistance administration (MAA)-covered dental services that are not covered by their plan, under fee-for-service.

[Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 USC 1396d(a), CFR 440.100 and 440.225. 99-07-023, § 388-535-1060, filed 3/10/99, effective 4/10/99.]

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

     (i) Practice dentistry or specialties of dentistry;

     (ii) Practice medicine and osteopathy for:

     (A) Oral surgery procedures; or

     (B) Providing fluoride varnish under EPSDT;

     (iii) Practice as dental hygienists;

     (iv) Provide denture services;

     (v) Practice ((anesthesiology)) anesthesia; or

     (vi) Provide conscious sedation, when certified by the department of health and when providing that service in dental offices for dental treatments.

     (b) Facilities that are:

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

     (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; and

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

     (2) MAA pays licensed providers participating in the MAA dental program for only those services that are within their scope of practice.

     (3) See WAC 388-502-0020 for provider documentation and record retention requirements. MAA may require additional documentation under specific sections in this chapter.

     (4) See WAC 388-502-0100 and 388-502-0150 for provider billing and payment requirements.

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

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

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

[]

     Reviser's note: The unnecessary strike-through and underscoring in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.
AMENDATORY SECTION(Amending WSR 99-07-023, filed 3/10/99, effective 4/10/99)

WAC 388-535-1080   Covered dental-related services.   (1) The medical assistance administration (MAA) pays ((only)) for covered dental and dental-related services((, equipment, and supplies)) listed in this section only when they are:

     (a) Within the scope of an eligible client's medical care program;

     (b) ((Dentally)) Medically necessary; and

     (c) Within accepted dental or medical practice standards and are:

     (i) Consistent with a diagnosis of dental disease or condition; and

     (ii) Reasonable in amount and duration of care, treatment, or service.

     (2) MAA covers the following dental-related services ((are covered:

     (a) Oral health evaluations and assessments.

     (i) Oral health evaluations no more than once every six months.

     (ii) The evaluation services must be documented in the client's dental file.

     (iii) These evaluations must include:

     (A) A comprehensive oral health and developmental history;

     (B) An assessment of physical and oral health development status;

     (C) Health education, including anticipatory guidance; and

     (D) Oral health status.

     (b) Dentally necessary services for the identification of dental problems or the prevention of dental disease subject to limitations of this chapter;

     (c) Prophylaxis treatment is allowed:

     (i) Once every twelve months for adults including nursing facility clients.

     (ii) Once every six months for children.

     (iii) Three times a calendar year for clients of the division of developmental disabilities.

     (d) Dental services or treatment necessary for the relief of pain and infections, including removal of symptomatic wisdom teeth. Routine removal of asymptomatic wisdom teeth without justifiable medical indications is not covered;

     (e) Restoration of teeth and maintenance of dental health subject to limitations of WAC 388-535-1100, Dental services not covered;

     (f) Complex orthodontic treatment for severe handicapping dental needs as specified in WAC 388-535-1250, Orthodontic coverage for DSHS clients;

     (g) Complete and partial dentures, and necessary modifications, repairs, rebasing, relining and adjustments of dentures subject to the limitations of WAC 388-535-1240, Dentures;

     (h) Dentally necessary oral surgery when coordinated with the client's managed care plan (if any);

     (i) Endodontic (root canal) therapies for permanent teeth except for wisdom teeth;

     (j) Nitrous oxide only when medically justified and a component of behavior management;

     (k) Crowns as described in WAC 388-535-1230, Crowns;

     (l) Therapeutic pulpotomies, once per tooth; and

     (m) Sealants for:

     (i) Occlusal surfaces of only these:

     (A) Permanent teeth two, three, fourteen, fifteen, eighteen, nineteen, thirty and thirty-one; and

     (B) Primary teeth A, B, I, J, K, L, S and T.

     (ii) Lingual pits of teeth seven and ten;

     (iii) Teeth with no decay;

     (iv) Children only; and

     (v) Once per tooth in a three-year period.)):

     (a) Medically necessary services for the identification of dental problems or the prevention of dental disease, subject to the limitations of this chapter;

     (b) Oral health evaluations and assessments, which must be documented in the client's file according to WAC 388-502-0020, as follows:

     (i) MAA allows a comprehensive oral evaluation once per provider as an initial examination, and it must include:

     (A) An oral health and developmental history;

     (B) An assessment of physical and oral health status; and

     (C) Health education, including anticipatory guidance.

     (ii) MAA allows periodic oral evaluations once every six months. Six months must elapse between the comprehensive oral evaluation and the first periodic oral evaluation.

     (iii) MAA allows limited oral evaluations only when the provider performing the limited oral evaluation is not providing pre-scheduled dental services for the client. The limited oral evaluation must be:

     (A) To provide limited or emergent services for a specific dental problem; or

     (B) To provide an evaluation for a referral.

     (c) Radiographs (x-rays) for children and adults, as follows:

     (i) Intraoral (complete series, including bitewings) - once in a three-year period;

     (ii) Bitewings - total of four every twelve months;

     (iii) Panoramic, for oral surgical purposes only, as follows:

     (A) Not allowed with an intraoral complete series; and

     (B) Once in a three-year period, except for preoperative or postoperative surgery cases. Preoperative x-rays must be provided within fourteen days prior to surgery, and postoperative x-rays must be provided within thirty days after surgery.

     (d) Fluoride treatment (either gel or varnish, but not both) as follows (additional applications require prior authorization):

     (i) For children through age eighteen, topical application of:

     (A) Fluoride gel, once every six months; or

     (B) Fluoride varnish, up to three times in a twelve-month period.

     (ii) For adults age nineteen through sixty-four, topical application of fluoride gel or varnish for xerostomia only; this requires prior authorization. See subsection (3) of this section for clients of the division of developmental disabilities;

     (iii) For adults age sixty-five and older, topical application of fluoride gel or varnish for only:

     (A) Rampant root surface decay; or

     (B) Xerostomia.

     (e) Sealants for children only, once per tooth in a three-year period for:

     (i) The occlusal surfaces of:

     (A) Permanent teeth two, three, fourteen, fifteen, eighteen, nineteen, thirty, and thirty-one only; and

     (B) Primary teeth A, B, I, J, K, L, S, and T only.

     (ii) The lingual pits of teeth seven and ten; and

     (iii) Teeth with no decay.

     (f) Prophylaxis treatment, which is allowed:

     (i) Once every twelve months for adults age nineteen and older, including nursing facility clients;

     (ii) Once every six months for children age eight through eighteen;

     (iii) Only as a component of oral hygiene instruction for children through age seven; and

     (iv) For clients of the division of developmental disabilities, see subsection (3) of this section.

     (g) Space maintainers, for children through age eighteen only, as follows:

     (i) Fixed (unilateral type), one per quadrant;

     (ii) Fixed (bilateral type), one per arch; and

     (iii) Recementation of space maintainer, once per quadrant or arch.

     (h) Amalgam or composite restorations, as follows:

     (i) Once in a two-year period; and

     (ii) For the same surface of the same tooth.

     (i) Crowns as described in WAC 388-535-1230, Crowns;

     (j) Restoration of teeth and maintenance of dental health, subject to limitations of WAC 388-535-1100 and as follows:

     (i) Multiple restorations involving the proximal and occlusal surfaces of the same tooth are considered to be a multisurface restoration, and are reimbursed as such; and

     (ii) Proximal restorations that do not involve the incisal angle in the anterior tooth are considered to be a two-surface restoration, and are reimbursed as such;

     (k) Endodontic (root canal) therapies for permanent teeth except for wisdom teeth;

     (l) Therapeutic pulpotomies, once per tooth, on primary teeth only;

     (m) Pulp vitality test, as follows:

     (i) Once per day (not per tooth);

     (ii) For diagnosis of emergency conditions only; and

     (iii) Not allowed when performed on the same date as any other procedure, with the exception of an emergency examination or palliative treatment.

     (n) Periodontal scaling and root planing as follows:

     (i) For clients age nineteen and older only. See subsection (3) of this section for clients of the division of developmental disabilities;

     (ii) Only when the client has radiographic (x-ray) evidence of periodontal disease. There must be supporting documentation, including complete periodontal charting and a definitive periodontal diagnosis;

     (iii) Once per quadrant in a twenty-four month period; and

     (iv) Not allowed when performed on the same date of service as adult prophylaxis, gingivectomy, or gingivoplasty.

     (o) Subject to WAC 388-535-1240 and as follows, complete and partial dentures, and necessary modifications, repairs, rebasing, relining, and adjustments of dentures (includes partial payment in certain situations for laboratory and professional fees for dentures and partials as specified in WAC 388-535-1240(5)). MAA covers:

     (i) One set of dentures per client in a ten-year period, with the exception of replacement dentures which may be allowed as specified in WAC 388-535-1240(4); and

     (ii) Partials as specified in WAC 388-535-1240(2), once every five years.

     (p) Complex orthodontic treatment for severe handicapping dental needs as specified in chapter 388-535A WAC, Orthodontic services;

     (q) Occlusal orthotic appliance for temporomandibular joint disorder (TMJ) or bruxism, one in a two-year period;

     (r) Medically necessary oral surgery when coordinated with the client's managed care plan (if any);

     (s) Dental services or treatment necessary for the relief of pain and infections, including removal of symptomatic wisdom teeth. MAA does not cover routine removal of asymptomatic wisdom teeth without justifiable medical indications;

     (t) Behavior management for children through age eighteen only, whose documented behavior requires the assistance of more than one additional dental professional staff to protect the client from self-injury during treatment. See subsection (3) of this section for clients of the division of developmental disabilities.

     (u) Nitrous oxide for children through age eighteen only, when medically necessary. See subsection (3) of this section for clients of the division of developmental disabilities.

     (v) Professional visits, as follows:

     (i) Bedside call at a nursing facility or residence, at the physician's request - one per day (see subsection (7) of this section).

     (ii) Hospital call, including emergency care - one per day.

     (w) Emergency palliative treatment, as follows:

     (i) Allowed only when no other definitive treatment is performed on the same day; and

     (ii) Documentation must include tooth designation and a brief description of the service.

     (3) For clients ((identified by the department as developmentally disabled, the following preventive services may be allowed more frequently than the limits listed in (3) of this section)) of the division of developmental disabilities, MAA allows services as follows:

     (a) Fluoride application, either varnish or gel, but not both - three times per calendar year;

     (b) Periodontal scaling and root planing - once every six months; ((and))

     (c) ((Prophylaxis scaling and coronal polishing.)) Prophylaxis - three times per calendar year;

     (d) Nitrous oxide;

     (e) Behavior management that requires the assistance of more than one additional dental professional staff and the use of advanced behavior techniques; and

     (f) Panoramic radiographs, with documentation that behavior management is required.

     (4) ((Panoramic radiographs are allowed only for oral surgical or orthodontic purposes.

     (5) The department)) MAA covers ((dentally)) medically necessary services provided in a hospital under the direction of a physician or dentist for:

     (a) The care or treatment of teeth, jaws, or structures directly supporting the teeth if the procedure requires hospitalization; and

     (b) Short stays when the procedure cannot be done in an office setting. See WAC ((388-550-1100(4))) 388-550-1100(6), Hospital coverage.

     (5) MAA covers anesthesia for medically necessary services as follows:

     (a) The anesthesia must be administered by:

     (i) An oral surgeon;

     (ii) An anesthesiologist;

     (iii) A Certified Registered Nurse Anesthetist (CRNA); or

     (iv) A general dentist who has a current conscious sedation permit from the department of health (DOH).

     (b) MAA reimburses for anesthesia services per WAC 388-535-1350.

     (6) For clients residing in nursing facilities or group homes:

     (a) Dental services must be requested by the client or a referral for services made by the attending physician, ((facility)) the director of nursing or the nursing facility supervisor, or the client's legal guardian;

     (b) Mass screening for dental services of clients residing in a facility is not permitted; and

     (c) Nursing facilities must provide dental-related necessary services per WAC ((388-97-225)) 388-97-012, Nursing facility care.

     (7) A request to exceed stated limitations or other restrictions on covered services is called a limitation extension (LE), which is a form of prior authorization. MAA evaluates and approves requests for LE for dental-related services when medically necessary, under the provisions of WAC 388-501-0165.

[Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 USC 1396d(a), CFR 440.100 and 440.225. 99-07-023, § 388-535-1080, filed 3/10/99, effective 4/10/99.]

     (a) Required by a physician as a result of an EPSDT((/Healthy Kids)) screen((:

     (i) Except that all of the orthodontic limitations of WAC 388-535-1250, Orthodontic coverage for DSHS clients, still apply; and

     (ii) Such services must be dentally necessary)) as provided under chapter 388-534 WAC;

     (b) Included in ((a)) an MAA waivered program; or

     (c) Part of one of the Medicare programs for qualified Medicare beneficiaries (QMB) except for QMB-only, which is not covered.

     (2) MAA does not cover:

     (a) ((Services, procedures, treatment, devices, drugs, or application of associated services which MAA or the Health Care Financing Administration (HCFA) consider investigative or experimental on the date the services are provided;

     (b) Cosmetic treatment or surgery, except for medically or dentally necessary reconstructive surgery to correct defects attributable to an accident, birth defect, or illness;

     (c) Teeth whitening;

     (d) Orthodontic care for adults;

     (e) Orthodontic care for cosmetic reasons and for children who do not meet the criteria in WAC 388-535-1250, Orthodontic coverage for DSHS clients;

     (f) Any service specifically excluded by statute;

     (g) More costly services when less costly equally effective services as determined by the department are available;

     (h) Nonmedical equipment, supplies, personal or comfort items and/or services;

     (i) Root planing for children unless clients of the division of developmental disabilities;

     (j) Root canal services for primary teeth;

     (k) Routine fluoride treatments for adults, unless clients of the division of developmental disabilities;

     (l) Extraction of asymptomatic teeth:

     (i) Except as a necessary part of orthodontic treatment, or      (ii) Unless their removal is the most cost effective dental procedure related to dentures;

     (m) Crowns for wisdom teeth; and

     (n) Amalgam or acrylic build-up for wisdom teeth.

     (3) MAA does not pay for the following services/supplies:

     (a) Missed or canceled appointments;

     (b) Provider mileage or travel costs;

     (c) Take-home drugs;

     (d) Dental supplies such as toothbrushes (manual, automatic, or electric), toothpaste, floss, or whiteners;

     (e) Educational supplies;

     (f) Reports, client charts, insurance forms, copying expenses;

     (g) Service charges/delinquent payment fees;

     (h) Dentist's time writing prescriptions or calling in prescriptions or prescription refills to a pharmacy;

     (i) Supplies used in conjunction with an office visit;

     (j) Transitional/immediate dentures;

     (k) Teeth implants including follow up and maintenance;

     (l) Bridges;

     (m) Nonemergent oral surgery for adults performed in an inpatient setting;

     (n) Minor bone grafts; or

     (o) Temporary crowns)) Any service specifically excluded by statute;

     (b) More costly services when less costly, equally effective services as determined by the department are available;

     (c) Services, procedures, treatment, devices, drugs, or application of associated services which the department or the Centers for Medicare and Medicaid Services (CMS) (formerly known as the Health Care Financing Administration (HCFA)) consider investigative or experimental on the date the services were provided;

     (d) Routine fluoride treatments (gel or varnish) for adults, unless the clients are:

     (i) Clients of the division of developmental disabilities;

     (ii) Diagnosed with xerostomia, in which case the provider must request prior authorization; or

     (iii) High-risk adults sixty-five and over. High-risk means the client has at least one of the following:

     (A) Rampant root surface decay; or

     (B) Xerostomia.

     (e) Crowns, as follows:

     (i) For wisdom and peg teeth;

     (ii) Laboratory processed crowns for posterior teeth;

     (iii) Temporary crowns, including stainless steel crowns placed as temporary crowns; and

     (iv) Post and core for crowns.

     (f) Root canal services for primary or wisdom teeth;

     (g) Root planing for children, unless they are clients of the division of developmental disabilities;

     (h) Bridges;

     (i) Transitional or treatment dentures;

     (j) Teeth implants, including follow up and maintenance;

     (k) Cosmetic treatment or surgery, except for medically necessary reconstructive surgery to correct defects attributable to an accident, birth defect, or illness;

     (l) Porcelain margin extensions (also known as crown lengthening), due to receding gums;

     (m) Extraction of asymptomatic teeth;

     (n) Minor bone grafts;

     (o) Nonemergent oral surgery for adults performed in an inpatient setting, except for the following:

     (i) For clients of the division of developmental disabilities, or for children eighteen years of age or younger whose surgeries cannot be performed in an office setting. This requires written prior authorization for the inpatient hospitalization; or

     (ii) As provided in WAC 388-535-1080(4).

     (p) Dental supplies such as toothbrushes (manual, automatic, or electric), toothpaste, floss, or whiteners;

     (q) Dentist's time writing prescriptions or calling in prescriptions or prescription refills to a pharmacy;

     (r) Educational supplies;

     (s) Missed or canceled appointments;

     (t) Nonmedical equipment, supplies, personal or comfort items or services;

     (u) Provider mileage or travel costs;

     (v) Service charges or delinquent payment fees;

     (w) Supplies used in conjunction with an office visit;

     (x) Take-home drugs;

     (y) Teeth whitening; or

     (z) Restorations for anterior or posterior wear with no evidence of decay.

     (3) MAA evaluates a request for any service that is listed as noncovered under the provisions of WAC 388-501-0165.

[Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 USC 1396d(a), CFR 440.100 and 440.225. 99-07-023, § 388-535-1100, filed 3/10/99, effective 4/10/99. Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090. 96-01-006 (Order 3931), § 388-535-1100, filed 12/6/95, effective 1/6/96.]

     (a) General assistance unemployable (GAU); and

     (b) Alcohol and drug abuse treatment and support act (ADATSA) (GAU-W).

     (2) The medical assistance administration (MAA) covers the dental services described and limited in this chapter for clients eligible for GAU or GAU-W only when those services are provided as part of a medical treatment for:

     (a) Apical abscess verified by clinical examination, and treated by:

     (i) Open and drain palliative treatment;

     (ii) Tooth extraction; or

     (iii) Root canal;

     (b) Cysts or tumor therapies;

     (c) Maxillofacial fracture;

     (d) Radiation therapy for cancer of the mouth, only for a total dental extraction performed prior to and because of that radiation therapy;

     (e) Sequestrectomies;

     (f) Systemic or presystemic cancer, only for oral hygiene related to those conditions; or

     (g) Tooth fractures (limited to extraction).

     (3) MAA may require prior authorization for any dental treatment provided to a GAU or GAU-W client.

[]

     (1) Nonemergent inpatient hospital dental admissions as described under WAC ((388-550-1100(1) Hospital coverage)) 388-535-1100 (2)(o) and 388-550-1100(1);

     (2) ((Orthodontic treatment as described under WAC 388-535-1250)) Crowns as described in WAC 388-535-1230;

     (3) Dentures as described in WAC 388-535-1240;

     (4) ((Crowns as described in WAC 388-535-1230)) Routine fluoride treatment (gel or varnish) for adults age nineteen through sixty-four who are diagnosed with xerostomia; and

     (5) Selected procedures identified by the medical assistance administration (MAA((,))) and published in its current dental billing instructions, which are available from MAA ((at)) in Olympia, Washington.

[Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 USC 1396d(a), CFR 440.100 and 440.225. 99-07-023, § 388-535-1200, filed 3/10/99, effective 4/10/99. Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090. 96-01-006 (Order 3931), § 388-535-1200, filed 12/6/95, effective 1/6/96.]

     (1) ((When requesting prior authorization, the dental provider must submit to MAA, in writing, sufficient objective clinical information to establish dental necessity including, but not limited to)) MAA requires a dental provider who is requesting prior authorization to submit sufficient objective clinical information to establish medical necessity. The request must be submitted in writing on an American Dental Association (ADA) claim form, which may be obtained by writing to the American Dental Association, 211 East Chicago Avenue, Chicago, Illinois 60611. The request must include at least all of the following:

     (a) Physiological description of the disease, injury, impairment, or other ailment;

     (b) X-ray(s);

     (c) Treatment plan;

     (d) Study model, if requested; and

     (e) Photographs, if requested.

     (2) ((When the requested service meets the criteria in WAC 388-535-1080, Covered services, it will be authorized)) MAA authorizes requested services that meet the criteria in WAC 388-535-1080.

     (3) MAA denies a request for dental services ((will be denied)) when the requested service is:

     (a) Not ((dentally)) medically necessary; or

     (b) A service, procedure, treatment, device, drug, or application of associated service which ((MAA)) the department or the Centers for Medicare and Medicaid Services (CMS) (formerly known as the Health Care Financing Administration (HCFA)) consider investigative or experimental on the date the service is provided.

     (4) MAA may require second opinions and/or consultations ((may be required)) before ((the authorization of)) authorizing any ((elective)) procedure.

     (5) Authorization is valid only if the client is eligible for covered services on the date of service.

     (((6) Miscellaneous or unspecified procedures may require prior authorization at MAA's discretion.))

[Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 USC 1396d(a), CFR 440.100 and 440.225. 99-07-023, § 388-535-1220, filed 3/10/99, effective 4/10/99.]

     (a) Stainless steel((,)). MAA considers these as permanent crowns, and does not cover them as temporary crowns; and

     (b) Nonlaboratory resin for primary anterior teeth.

     (2) MAA does not cover laboratory-processed crowns for posterior teeth.

     (3) MAA requires prior authorization for the following crowns, which are limited to single restorations for permanent anterior (upper and lower) teeth:

     (a) ((Porcelain fused to a high noble metal)) Resin (laboratory);

     (b) Porcelain ((fused to a predominately base metal)) with ceramic substate;

     (c) Porcelain fused to ((a)) high noble metal;

     (d) Porcelain ((with ceramic substrate)) fused to predominantly base metal; and

     (e) ((Full cast high noble metal;

     (f) Full cast predominately base metal;

     (g) Full cast noble metal; and

     (h) Resin (laboratory))) Porcelain fused to noble metal.

     (4) Criteria for covered crowns as described in subsections (1) and (3) of this section:

     (a) Crowns may be authorized when the crown is ((dentally)) medically necessary.

     (b) Coverage is based upon a supportable five year prognosis that the client will retain the tooth if the tooth is crowned. The provider must submit the following client information:

     (i) The overall condition of the mouth;

     (ii) Oral health status;

     (iii) ((Patient)) Client maintenance of good oral health status;

     (iv) Arch integrity; and

     (v) Prognosis of remaining teeth (that is, no more involved than periodontal case type II).

     (c) Anterior teeth must show traumatic or pathological destruction to loss of at least one incisal angle.

     (5) The laboratory processed crowns described in subsection (3) are covered:

     (a) Only when a lesser service will not suffice because of extensive coronal destruction, and treatment is beyond intracoronal restoration;

     (b) Only once per permanent tooth in a five year period;

     (c) For endodontically treated anterior teeth only after satisfactory completion of the root canal therapy. Post-endodontic treatment X-rays must be submitted for prior authorization of these crowns.

     (6) MAA reimburses only for covered crowns as described in subsections (1) and (3) of this section. The reimbursement is full payment; all of the following are included in the reimbursement and must not be billed separately:

     (a) Tooth and soft tissue preparation;

     (b) Amalgam or acrylic build-ups;

     (c) Temporary restoration;

     (d) Cement bases;

     (e) Insulating bases;

     (f) Impressions;

     (g) Seating; and

     (h) Local anesthesia.

[Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.500, 74.09.520. 01-07-077, § 388-535-1230, filed 3/20/01, effective 4/20/01. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 USC 1396d(a), CFR 440.100 and 440.225. 99-07-023, § 388-535-1230, filed 3/10/99, effective 4/10/99.]

     (c) A final set (constructed after the client has received immediate or initial dentures).

     (2) ((Partial dentures are covered under these limits)) The first set of dentures must be of the structure and quality to be considered the primary set. MAA does not cover transitional or treatment dentures.

     (3) MAA covers partials (resin and cast base) once every five years, except as noted in subsection (4) of this section, and subject to the following limits:

     (a) Cast base partials only when replacing three or more teeth per arch excluding wisdom teeth; and

     (b) No partials are covered when they replace wisdom teeth only.

     (((3))) (4) Except as stated below, MAA does not require prior authorization for replacement dentures or partials ((is not required)) when:

     (a) The client's existing dentures or partials ((are)) meet any of the following conditions. MAA requires prior authorization for replacement dentures or partials requested within one year of the seat date. The dentures or partials must be:

     (i) No longer serviceable and cannot be relined or rebased; or

     (ii) ((Are lost; or

     (iii) Are)) Damaged beyond repair.

     (b) The client's health would be adversely affected by absence of dentures;

     (c) The client has been able to wear dentures successfully; ((and))

     (d) The ((denture meets)) dentures or partials meet the criteria of ((dentally)) medically necessary((.

     (4) Payment (which may be partial) for laboratory and professional fees for dentures and partials requires prior authorization when the client)); and

     (e) The dentures are replacing lost dentures, and the replacement set does not exceed MAA's limit of one set in a ten-year period as stated in subsection (1) of this section.

     (5) MAA does not reimburse separately for laboratory and professional fees for dentures and partials. However, MAA may partially reimburse for these fees when the provider obtains prior authorization and the client:

     (a) Dies;

     (b) Moves from the state;

     (c) Cannot be located; or

     (d) Does not participate in completing the dentures.

     (((5))) (6) The provider must document in the client's medical or dental record:

     (a) Justification for replacement of dentures; ((and))

     (b) Charts of missing teeth, for replacement of partials; and

     (c) Receipts for laboratory costs or laboratory records and notes.

     (((6))) (7) For billing purposes, the provider may use the impression date ((may be used)) as the service date for dentures, including partials, only when:

     (a) Related dental services including laboratory services were provided during a client's eligible period; and

     (b) The client is not eligible at the time of delivery.

     (8) For billing purposes, the provider may use the delivery date as the service date when the client is using the first set of dentures in lieu of noncovered transitional or treatment dentures after oral surgery.

     (9) MAA includes the cost of relines and adjustments that are done within six months of the seat date in the reimbursement for the dentures.

     (10) MAA covers one rebase in a five-year period; the dentures must be at least three years old.

     (11) The requirements in this section also apply to overdentures.

[Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 USC 1396d(a), CFR 440.100 and 440.225. 99-07-023, § 388-535-1240, filed 3/10/99, effective 4/10/99.]

     (1) For covered dental-related services provided to eligible clients, MAA pays dentists and related providers on a fee-for-service or contractual basis, subject to the exceptions and restrictions listed under WAC 388-535-1100((, Dental services not covered, and WAC)) and 388-535-1400((, Dental payment limits)).

     (2) ((MAA may pay providers a higher reimbursement rate for selected dental services provided to children in order to increase children's access to dental services.

     (3))) MAA sets maximum allowable fees for dental services provided to children ((are set)) as follows:

     (a) ((The department's)) MAA's historical reimbursement rates for various procedures are compared to usual and customary charges.

     (b) ((The department)) MAA consults with ((and seeks input from)) representatives of the provider community to identify program areas and concerns that need to be addressed.

     (c) ((The department)) MAA consults with dental experts and public health professionals to identify and prioritize dental services and procedures ((in terms of)) for their effectiveness in improving or promoting children's dental health.

     (d) Legislatively authorized vendor rate increases and/or earmarked appropriations for children's dental services are allocated to specific procedures based on ((this priority list)) the priorities identified in (c) of this subsection and considerations of access to services.

     (e) Larger percentage increases may be given to those procedures which have been identified as most effective in improving or promoting children's dental health.

     (f) Budget-neutral rate adjustments are made as appropriate based on the department's evaluation of utilization trends, effectiveness of interventions, and access issues.

     (((4))) (3) MAA reimburses dental general anesthesia services for ((all)) eligible clients ((are reimbursed)) on the basis of base anesthesia units plus time. Payment for dental general anesthesia is calculated as follows:

     (a) Dental procedures are assigned an anesthesia base unit of five;

     (b) ((Twelve)) Fifteen minutes constitute one unit of time. When a dental procedure requiring dental general anesthesia results in multiple time units and a remainder (less than ((twelve)) fifteen minutes), the remainder or fraction is considered as one time unit;

     (c) Time units are added to the anesthesia base unit of five and multiplied by the anesthesia conversion factor;

     (d) The formula for determining payment for dental general anesthesia is: (5.0 base anesthesia units + time units) x conversion factor = payment.

     (4) When billing for anesthesia, the provider must show the actual beginning and ending times on the claim. 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 safety placed under post-operative supervision).

     (5) MAA may pay anesthesiologists ((may be paid)) for general dental anesthesia provided in dental offices. Only anesthesiologists specially contracted by ((MAA will be)) the department are paid an additional fee for that service.

     (6) Dental hygienists who have a contract with MAA are paid at the same rate as dentists who have a contract with MAA, for services allowed under The Dental Hygienist Practice Act, which is available from the department of health, Olympia, Washington.

     (7) Licensed denturists ((or dental laboratories billing independently are paid at MAA's allowance for prosthetics (dentures and partials) services)) who have a contract with MAA are paid at the same rate as dentists who have a contract with MAA, for providing dentures and partials.

     (8) MAA makes fee schedule changes ((are made)) whenever the legislature authorizes vendor rate increases or decreases ((are authorized by the legislature)).

     (9) ((The department)) MAA may adjust maximum allowable fees to reflect changes in ((the)) services or procedure code descriptions.

[Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 USC 1396d(a), CFR 440.100 and 440.225. 99-07-023, § 388-535-1350, filed 3/10/99, effective 4/10/99. Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090. 96-01-006 (Order 3931), § 388-535-1350, filed 12/6/95, effective 1/6/96.]

     (2) Participating providers must bill ((the department)) MAA their usual and customary fees.

     (3) Payment for dental services is based on ((the department's)) MAA's schedule of maximum allowances. Fees listed in the MAA fee schedule are the maximum allowable fees.

     (4) ((Payment to)) MAA pays the provider ((will be)) the lesser of the billed charge (usual and customary fee) or ((the department's)) MAA's maximum allowable fee.

     (5) ((If a covered service is performed for which no fee is listed, the service is paid)) MAA pays "by report" on a case-by-case basis ((as determined by MAA)), for a covered service that does not have a set fee.

     (6) 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 partials as stated in WAC 388-535-1240.

     (7) The client is responsible for payment of any dental treatment or service received during any period of ineligibility with the exception described in WAC 388-535-1240(4) even if the treatment was started when the client was eligible.

[Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 USC 1396d(a), CFR 440.100 and 440.225. 99-07-023, § 388-535-1400, filed 3/10/99, effective 4/10/99. Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090. 96-01-006 (Order 3931), § 388-535-1400, filed 12/6/95, effective 1/6/96.]

     No payment will be made to a dentist for services performed and billed by an independent denturist)) The medical assistance administration (MAA) does not directly reimburse denture laboratories. MAA's reimbursement for dentures, partials, and overdentures includes laboratory fees. The provider is responsible to pay a denture laboratory for services furnished to the provider.

[Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 USC 1396d(a), CFR 440.100 and 440.225. 99-07-023, § 388-535-1450, filed 3/10/99, effective 4/10/99. Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090. 96-01-006 (Order 3931), § 388-535-1450, filed 12/6/95, effective 1/6/96.]

[Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 USC 1396d(a), CFR 440.100 and 440.225. 99-07-023, § 388-535-1500, filed 3/10/99, effective 4/10/99. Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090. 96-01-006 (Order 3931), § 388-535-1500, filed 12/6/95, effective 1/6/96.]

     (2) The medical assistance administration (MAA) does not cover out-of-state dental care ((received by)) for clients receiving ((medical care)) services ((())under state-((only funding) is not covered)) funded only programs.

     (3) Eligible clients in MAA-designated border areas may receive the same dental services as if provided in state.

     (4) Dental providers who are out-of-state must meet the same criteria for payment as in-state providers, including the requirements to contract with MAA. See WAC 388-535-1070, Dental-related services provider information.

[Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520 and 74.09.700, 42 USC 1396d(a), CFR 440.100 and 440.225. 99-07-023, § 388-535-1550, filed 3/10/99, effective 4/10/99. Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090. 96-01-006 (Order 3931), § 388-535-1550, filed 12/6/95, effective 1/6/96.]

     The following sections of the Washington Administrative Code are repealed:

WAC 388-535-1010	Dental-related program introduction.
WAC 388-535-1150	Becoming a DSHS dental provider.
WAC 388-535-1260	Dental-related limits of state-only funded programs.

© Washington State Code Reviser's Office