Date of Adoption: September 9, 2003.

     Purpose: To avoid federal penalties, the department is amending these rules to be HIPAA-compliant (P.L. 104-191) by October 16, 2003. Also, to comply with requirements of the 2003-2005 State Omnibus Operating Budget (ESSB 5404), the department is incorporating into rule the 25% reduction in adult dental benefits.

     These rules replace emergency rules filed as WSR 03-16-046.

     Citation of Existing Rules Affected by this Order: Repealing WAC 388-535-1120; and amending WAC 388-535-1350, 388-535-1400, and 388-535-1450.

     Statutory Authority for Adoption: RCW 74.04.050, 74.04.057, 74.08.090, and 74.09.530.

     Other Authority: ESSB 5404 (chapter 25, Laws of 2003 1st sp.s.), P.L. 104-191.

      Adopted under notice filed as WSR 03-15-138 on July 23, 2003 (Part 4 of 4).

     Changes Other than Editing from Proposed to Adopted Version: The following changes were made in the proposed rules as a result of comments received, federal requirements; clarifications; and editorial and typographical corrections. New text is underlined, and deleted text struck through:

     WAC 388-535-1280 (1)(h)(i) Periodontal charting when radiographs do not sufficiently support the medical necessity for extractions and diagnosis;

     WAC 388-535-1290(1) The medical assistance administration (MAA) requires prior authorization for the dentures (complete or immediate), replacement dentures, partial dentures, and replacement partial dentures that are described in this section.

     WAC 388-535-1290 (2)(b)(ii) Allowed only when the applicable criteria in subsection (5) (6) of this section are met.

     WAC 388-535-1290 (2)(d)(ii) Allowed only when the applicable criteria in subsection (5) (6) of this section are met.

     WAC 388-535-1290(5) MAA covers complete dentures and partial denture repairs when medically necessary.

     WAC 388-535-1290 (5) (6) In addition to the prior authorization requirements and other limitations in this section, all replacement complete dentures and cast metal framework partial dentures are allowed once in a ten-year period and must:

     WAC 388-535-1290 (6) (7) For billing purposes,...

     WAC 388-535-1290 (7) (8) A provider must retain...

     WAC 388-535-1290 (8) (9) MAA does not pay...

     WAC 388-535-1290 (9) (10) MAA does not pay...

     WAC 388-535-1350 (10) MAA does not pay separately for chart or record setup, or for completion of reports, forms, or charting. The fees for these services are included in MAA's reimbursement for comprehensive oral evaluations or limited oral evaluations.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 1, Repealed 0; or Recently Enacted State Statutes: New 3, Amended 2, Repealed 1.

     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 0, 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 3, Amended 3, Repealed 1.
     Effective Date of Rule: Thirty-one days after filing.

September 9, 2003

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

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

     (2) Dentures and partial dentures as described in WAC 388-550-1290;

     (3) Fluoride treatment (gel or varnish) for clients age nineteen through sixty-four who are diagnosed with xerostomia; and

     (4) Selected procedures identified by the medical assistance administration (MAA) and published in its current dental billing instructions.

     (5) See WAC 388-535-1280 for obtaining prior authorization for dental-related services for adults.

[]

     (1) 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 Assoc6iation (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) The client's patient identification code (PIC);

     (b) The client's name and address;

     (c) The provider's name and address;

     (d) The provider's telephone and fax number (including area code);

     (e) The provider's MAA-assigned seven-digit provider number;

     (f) The physiological description of the disease, injury, impairment, or other ailment;

     (g) The most recent and relevant radiographs that are identified with client name, provider name, and date the radiograph was taken;

     (h) The treatment plan;

     (i) Periodontal when radiographs do not sufficiently support the medical necessity for extractions;

     (j) Study model, if requested; and

     (k) Photographs, if requested.

     (2) MAA considers requests for services according to WAC 388-535-1270.

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

     (a) Not listed in chapter 388-535 WAC as a covered service;

     (b) Not medically necessary;

     (c) A service, procedure, treatment, device, drug, or application of associated service that the department or the Centers for Medicare and Medicaid Services (CMS) consider investigative or experimental on the date the service is provided; or

     (d) Covered under another department program or by an agency outside the department.

     (4) MAA may require second opinions and/or consultations before authorizing any procedure.

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

[]

     (2) Subject to the criteria in this section and other applicable WAC, MAA covers the following for eligible adults:

     (a) Dentures, subject to the following limitations:

     (i) Only one complete maxillary denture and one complete mandibular denture allowed per client in a ten-year period, when constructed after the client has been without teeth for a period of time; or

     (ii) Only one immediate maxillary denture and one immediate mandibular denture allowed per client, per lifetime, and only when constructed prior to the removal of the client's teeth.

     (b) Replacement dentures, subject to the following limitations:

     (i) Only one replacement of a complete maxillary denture and one replacement of a complete mandibular denture allowed per client in a ten-year period; and

     (ii) Allowed only when the applicable criteria in subsection (6) of this section are met.

     (c) Partial dentures, subject to the following limitations:

     (i) Only one maxillary partial denture (resin) and one mandibular partial denture (resin) to replace one, two, or three missing anterior teeth per arch, allowed per client in a ten-year period; or

     (ii) Only one maxillary partial denture (cast metal framework) and one mandibular partial denture (cast metal framework) allowed per client in a ten-year period to replace:

     (A) Any combination of at least six anterior and posterior missing teeth per arch, excluding wisdom teeth; or

     (B) At least four anterior missing teeth per arch.

     (d) Replacement partial dentures, subject to the following limitations:

     (i) Only one replacement of a maxillary partial denture (cast metal framework) and a mandibular partial denture (cast metal framework) allowed per client in a ten-year period; and

     (ii) Allowed only when the applicable criteria in subsection (6) of this section are met.

     (3) Dentures must be of an acceptable structure and quality to meet the standard of care.

     (4) MAA covers complete denture and partial denture relines only once in a five-year period.

     (5) MAA covers complete dentures and partial denture repairs when medically necessary.

     (6) In addition to the prior authorization requirement and other limitations in this section, all replacement complete dentures and cast mental framework partial dentures are allowed once in a ten-year period and must:

     (a) Replace a complete maxillary denture, a complete mandibular denture, a maxillary partial denture (cast metal framework) or a mandibular partial denture (cast metal framework) (see subsection (2) of this section);

     (b) Replace dentures or partial dentures that are no longer serviceable and are unable to be relined;

     (c) Replace dentures or partial dentures that are damaged beyond repair;

     (d) Replace dentures or partial dentures that a client has been able to wear successfully; and

     (e) Be medically necessary, as defined in WAC 388-500-0005.

     (7) For billing purposes, a provider must:

     (a) Use the delivery date as the service date for the dentures and partial dentures; and

     (b) Use the impression date as the service date for dentures and partial dentures only when:

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

     (ii) The client is not eligible at the time of delivery; or

     (iii) The client does not return to obtain the dentures or partial dentures.

     (8) A provider must retain in a client's record:

     (a) Written laboratory prescriptions;

     (b) Receipts for laboratory fees;

     (c) Charts of missing teeth for partial dentures; and

     (d) Documentation that justifies the placement or replacement of dentures or partial dentures.

     (9) MAA does not pay separately for laboratory and professional fees for dentures and partial dentures. 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.

     (10) MAA does not pay separately for relines that are done within six months of the seat date. These procedures are included in the reimbursement for the dentures and partial dentures.

[]

     (1) For covered dental-related services provided to eligible clients, MAA pays dentists and ((related)) other eligible providers on a fee-for-service or contractual basis, subject to the exceptions and restrictions listed under WAC 388-535-1100 and 388-535-1400.

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

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

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

     (c) MAA consults with dental experts and public health professionals to identify and prioritize dental services and procedures 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 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.

     (3) MAA reimburses dental general anesthesia services for eligible clients 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) 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 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)) safely placed under post-operative supervision).

     (5) MAA ((may pay anesthesiologists for general dental anesthesia provided in dental offices. Only anesthesiologists specially contracted by the department are paid an additional fee for that service)) pays eligible providers listed in WAC 388-535-1070 for conscious sedation with parenteral and multiple oral agents, or for general anesthesia when the provider meets the criteria in this chapter and other applicable WAC.

     (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 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 whenever the legislature authorizes vendor rate increases or decreases.

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

     (10) MAA does not pay separately for chart or record setup, or for completion of reports, forms, or charting. The fees for these services are included in MAA's reimbursement for comprehensive oral evaluations or limited oral evaluations.

[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. 02-13-074, § 388-535-1350, 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 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 MAA their usual and customary fees.

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

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

     (5) MAA pays "by report" on a case-by-case basis, for a covered service that does not have a set fee.

     (6) Participating providers must bill a client according to WAC 388-502-0160, unless otherwise specified in this chapter.

     (7) 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)) partial dentures as described in WAC 388-535-1240 and 388-535-1290.

     (((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, 74.09.500, 74.09.520, 42 U.S.C. 1396d(a), 42 C.F.R. 440.100 and 440.225. 02-13-074, § 388-535-1400, 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 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.]

[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. 02-13-074, § 388-535-1450, 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 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.]

     The following section of the Washington Administrative Code is repealed:

WAC 388-535-1120

Coverage limits for dental-related services provided under state-only funded programs.

© Washington State Code Reviser's Office