Source: https://apps.leg.wa.gov/WAC/default.aspx?dispo=true&cite=182-535&full=true
Timestamp: 2020-02-18 09:27:27
Document Index: 385540435

Matched Legal Cases: ['§ 211', '§ 182', '§ 213', '§ 182', '§ 182', '§ 213', '§ 182', '§ 182', '§ 182', '§ 388', '§ 388', '§ 388', '§ 182', '§ 213', '§ 182', '§ 182', '§ 388', '§ 388', '§ 388', '§ 182', '§ 213', '§ 182', '§ 182', '§ 182', '§ 388', '§ 182', '§ 182', '§ 182', '§ 182', '§ 213', '§ 182', '§ 182', '§ 182', '§ 388', '§ 213', '§ 182', '§ 182', '§ 182', '§ 388', '§ 182', '§ 182', '§ 213', '§ 182', '§ 182', '§ 182', '§ 388', '§ 388', '§ 388', '§ 388', '§ 211', '§ 182', '§ 213', '§ 182', '§ 182', '§ 182', '§ 213', '§ 182', '§ 182', '§ 388', '§ 388', '§ 388', '§ 213', '§ 182', '§ 182', '§ 182', '§ 388', '§ 388', '§ 388', '§ 388', '§ 182', '§ 182', '§ 388', '§ 388', '§ 388', '§ 388', '§ 182', '§ 182', '§ 388', '§ 388', '§ 388', '§ 213', '§ 182', '§ 182', '§ 388', '§ 388', '§ 388', '§ 388']

PDF182-535-1050
PDF182-535-1060
(2) Managed care clients are eligible under apple health fee-for-service for covered dental-related services not covered by their managed care organization (MCO), subject to the provisions of this chapter and other applicable agency rules.
(4) Exception to rule procedures as described in WAC 182-501-0160 are not available for services that are excluded from a client's benefit package.
[Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 415 §§ 211 (1)(c) and 1111 (1)(c). WSR 19-20-047, § 182-535-1060, filed 9/25/19, effective 10/26/19. Statutory Authority: RCW 41.05.021, 41.05.160 and 2017 3rd sp.s. c 1 § 213 (1)(c). WSR 19-09-058, § 182-535-1060, filed 4/15/19, effective 7/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-20-097, § 182-535-1060, filed 10/3/17, effective 11/3/17. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535-1060, filed 3/25/14, effective 4/30/14. Statutory Authority: RCW 41.05.021. WSR 12-09-081, § 182-535-1060, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-535-1060, filed 6/30/11, effective 7/1/11. 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 03-19-077, § 388-535-1060, 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, § 388-535-1060, 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, § 388-535-1060, filed 3/10/99, effective 4/10/99.]
PDF182-535-1070
Dental-related services—Provider information.
(1) The following providers are eligible to enroll with the medicaid agency to furnish and bill for dental-related services provided to eligible clients:
(B) Providing conscious sedation with parenteral or multiple oral agents, deep sedation, or general anesthesia as a qualified professional under chapter 246-817 WAC; or
(2) Subject to the restrictions and limitations in this section and other applicable WAC, the agency pays licensed providers participating in the agency's dental program for only those services that are within their scope of practice.
(3) For the dental specialty of oral and maxillofacial surgery, the agency requires a dentist to meet the following requirements in order to be reimbursed for oral and maxillofacial surgery:
(a) The provider's professional organization guidelines;
(4) See WAC 182-502-0020 for provider documentation and record retention requirements. The agency requires additional dental documentation under specific sections in this chapter and as required by DOH under chapter 246-817 WAC.
(5) See WAC 182-502-0100 and 182-502-0150 for provider billing and payment requirements. Enrolled dental providers who do not meet the conditions in subsection (3) of this section must bill all claims using only the CDT codes for services that are identified in WAC and the agency's published billing instructions and provider notices. The agency does not reimburse for billed CPT codes when the dental provider does not meet the requirements in subsection (3)(a) of this section.
(6) See WAC 182-502-0160 for regulations concerning charges billed to clients.
(7) See WAC 182-502-0230 for provider payment reviews and dispute rights.
(8) See chapter 182-502A WAC for provider audits and the audit appeal process.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-20-097, § 182-535-1070, filed 10/3/17, effective 11/3/17. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535-1070, filed 3/25/14, effective 4/30/14. WSR 11-14-075, recodified as § 182-535-1070, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. WSR 05-06-092, § 388-535-1070, filed 3/1/05, effective 4/1/05. 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 03-19-077, § 388-535-1070, 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, § 388-535-1070, filed 6/14/02, effective 7/15/02.]
PDF182-535-1079
PDF182-535-1080
PDF182-535-1082
PDF182-535-1084
PDF182-535-1086
PDF182-535-1088
PDF182-535-1090
PDF182-535-1092
Dental-related services—Covered—Maxillofacial prosthetic services.
(1) Maxillofacial prosthetics are covered on a case-by-case basis and when prior authorized; and
[Statutory Authority: RCW 41.05.021, 41.05.160. WSR 16-18-033, § 182-535-1092, 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, § 182-535-1092, filed 3/25/14, effective 4/30/14. Statutory Authority: RCW 41.05.021. WSR 12-09-081, § 182-535-1092, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-535-1092, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. WSR 07-06-042, § 388-535-1092, filed 3/1/07, effective 4/1/07.]
PDF182-535-1094
Dental-related services—Covered—Oral and maxillofacial surgery services.
(b) Requires enrolled providers (oral and maxillofacial surgeons) who meet the conditions in WAC 182-535-1070(3) to bill claims using current procedural terminology (CPT) codes unless the procedure is specifically listed in the agency's current published billing guide as a CDT covered code (e.g., extractions).
(i) Clients age eight and younger;
(ii) Clients age nine through twenty. Prior authorization is required for the site of service; and
(d) For site-of-service and oral surgery CPT codes that require prior authorization, the agency requires the dental provider to submit current records (within the past twelve months), including:
(iii) Radiographs (X-rays);
(v) Written narrative/letter of medical necessity, including proposed billing codes.
(f) Covers simple and surgical extractions.
(i) Covers surgical extraction of unerupted teeth for clients.
(k) Covers biopsy of soft oral tissue, brush biopsy, and surgical excision of soft tissue lesions. Providers must keep all biopsy reports or findings in the client's dental record.
(l) Covers only the following excisions of bone tissue in conjunction with placement of complete or partial dentures:
(ii) Removal of torus palatinus or torus mandibularis;
(iii) Surgical reduction of osseous tuberosity.
(2) Alveoloplasty. The agency covers alveoloplasty. Prior authorization is not required.
(3) Surgical incisions. The agency covers the following surgical incision-related services:
(a) Uncomplicated intraoral and extraoral soft tissue incision and drainage of abscess. The agency does not cover this service when combined with an extraction or root canal treatment. Documentation supporting the medical necessity must be in the client's record.
(b) Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue. Documentation supporting the medical necessity for the service must be in the client's record.
(c) Frenuloplasty/frenulectomy for clients age six and younger without prior authorization.
(d) Frenuloplasty/frenulectomy for clients age seven through twelve. Prior authorization is required. Photos must be submitted to the agency with the prior authorization request. Documentation supporting the medical necessity for the service must be in the client's record.
(e) Surgical access of unerupted teeth for clients age twenty and younger. Prior authorization is required.
(4) Occlusal orthotic devices. (Refer to WAC 182-535-1098 (4)(c) for occlusal guard coverage and limitations on coverage.) The agency covers:
(a) Occlusal orthotic devices for clients age twelve through twenty. Prior authorization is required.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-06-003, § 182-535-1094, filed 2/21/19, effective 3/24/19; WSR 17-20-097, § 182-535-1094, filed 10/3/17, effective 11/3/17; WSR 16-18-033, § 182-535-1094, filed 8/26/16, effective 9/26/16; WSR 15-10-043, § 182-535-1094, filed 4/29/15, effective 5/30/15. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535-1094, filed 3/25/14, effective 4/30/14. Statutory Authority: RCW 41.05.021. WSR 12-09-081, § 182-535-1094, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-535-1094, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. WSR 07-06-042, § 388-535-1094, filed 3/1/07, effective 4/1/07.]
PDF182-535-1096
Dental-related services—Covered—Orthodontic services.
[Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535-1096, filed 3/25/14, effective 4/30/14. Statutory Authority: RCW 41.05.021. WSR 12-09-081, § 182-535-1096, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-535-1096, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. WSR 07-06-042, § 388-535-1096, filed 3/1/07, effective 4/1/07.]
PDF182-535-1098
PDF182-535-1099
PDF182-535-1100
PDF182-535-1220
Obtaining prior authorization for dental-related services.
(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.
(a) Additional radiographs (X-rays) (refer to WAC 182-535-1080(2));
(a) Is covered by another state agency program;
(b) Is covered by an entity outside the agency; or
[Statutory Authority: RCW 41.05.021 and 41.05.160. 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.]
PDF182-535-1245
(iii) Children's health program;
[Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 415 §§ 211 (1)(c) and 1111 (1)(c). WSR 19-20-047, § 182-535-1245, filed 9/25/19, effective 10/26/19. Statutory Authority: RCW 41.05.021, 41.05.160 and 2017 3rd sp.s. c 1 § 213 (1)(c). WSR 19-09-058, § 182-535-1245, filed 4/15/19, effective 7/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-20-097, § 182-535-1245, filed 10/3/17, effective 11/3/17; WSR 16-13-110, § 182-535-1245, filed 6/20/16, effective 8/1/16. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535-1245, filed 3/25/14, effective 4/30/14. WSR 11-14-075, recodified as § 182-535-1245, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 08-16-009, § 388-535-1245, filed 7/24/08, effective 8/24/08. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. WSR 07-06-042, § 388-535-1245, filed 3/1/07, effective 4/1/07. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.500, 42 U.S.C. 1396d(a), 42 C.F.R. 440.100 and .225. WSR 02-11-136, § 388-535-1245, filed 5/21/02, effective 6/21/02.]
PDF182-535-1270
PDF182-535-1350
(3) The agency pays eligible providers listed in WAC 182-535-1070 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.
[Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535-1350, filed 3/25/14, effective 4/30/14. Statutory Authority: RCW 41.05.021. WSR 12-09-081, § 182-535-1350, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-535-1350, filed 6/30/11, effective 7/1/11. 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 03-19-080, § 388-535-1350, 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, § 388-535-1350, 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 U.S.C. 1396d(a), C.F.R. 440.100 and 440.225. WSR 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. WSR 96-01-006 (Order 3931), § 388-535-1350, filed 12/6/95, effective 1/6/96.]
PDF182-535-1400
PDF182-535-1450
Payment for denture laboratory services.
This section applies to payment for denture laboratory services. The agency does not directly reimburse denture laboratories. The agency's reimbursement for complete dentures, partial dentures, and overdentures includes laboratory fees. The provider is responsible to pay a denture laboratory for services furnished at the request of the provider.
[Statutory Authority: RCW 41.05.021. WSR 12-09-081, § 182-535-1450, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-535-1450, filed 6/30/11, effective 7/1/11. 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 03-19-080, § 388-535-1450, 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, § 388-535-1450, 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 U.S.C. 1396d(a), C.F.R. 440.100 and 440.225. WSR 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. WSR 96-01-006 (Order 3931), § 388-535-1450, filed 12/6/95, effective 1/6/96.]
PDF182-535-1500
Payment for dental-related hospital services.
The agency pays for medically necessary dental-related services provided in an inpatient or outpatient hospital setting according to WAC 182-550-1100.
[Statutory Authority: RCW 41.05.021. WSR 12-09-081, § 182-535-1500, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-535-1500, filed 6/30/11, effective 7/1/11. 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, § 388-535-1500, 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, § 388-535-1500, filed 3/10/99, effective 4/10/99. Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090. WSR 96-01-006 (Order 3931), § 388-535-1500, filed 12/6/95, effective 1/6/96.]
PDF182-535-1550
Payment for dental care provided out-of-state.
See WAC 182-501-0180, 182-501-0182, and 182-501-0184 for services provided outside the state of Washington. See WAC 182-501-0175 for designated bordering cities.
[Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535-1550, filed 3/25/14, effective 4/30/14. WSR 11-14-075, recodified as § 182-535-1550, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.035. WSR 08-08-064, § 388-535-1550, filed 3/31/08, effective 5/1/08. 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, § 388-535-1550, 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, § 388-535-1550, filed 3/10/99, effective 4/10/99. Statutory Authority: Initiative 607, 1995 c 18 2nd sp.s. and 74.08.090. WSR 96-01-006 (Order 3931), § 388-535-1550, filed 12/6/95, effective 1/6/96.]