reglab/statecodes huggingface dataset:
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-533 - Maternity-related services › FIRST STEPS SERVICES FOR WOMEN AND INFANTS › Section 182-533-0378 - Infant case management-Documentation requirements

Current through Register Vol. 24-14, July 15, 2024
Providers must fulfill the documentation requirements
					 under WAC
					 182-502-0020 and the medicaid
					 agency's current billing instructions including:
(1) Required supervision records for infant
				  case managers;
(2) Continued
				  education verification and renewal of credentials for professional staff;
				  and
(3) Client records that include
				  consent forms and documentation for screening, assessments, care plans, case
				  management, and care coordination for each client.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-533 - Maternity-related services › FIRST STEPS SERVICES FOR WOMEN AND INFANTS › Section 182-533-0380 - Infant case management - Covered services

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency must cover infant
				  case management (ICM) services subject to the restrictions and limitations in
				  this section and other applicable WAC.
Covered services include:
(a) An initial in-person screening for ICM
				  services, which includes an assessment of risk factors and the development of
				  an individualized care plan;
(b)
				  Case management services and care coordination;
(c) Referral and linking the infant and
				  parent(s) to other services or resources;
(d) Advocacy for the infant and parent(s);
				  and
(e) Follow-up contact(s) with
				  the parent(s) to ensure the care plan continues to meet the needs of the infant
				  and parent(s).
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-533 - Maternity-related services › FIRST STEPS SERVICES FOR WOMEN AND INFANTS › Section 182-533-0385 - Infant case management - Noncovered services

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency must cover only those
				  services that are listed in WAC
				  182-533-0380.
(2) The medicaid agency must evaluate a
				  request for any noncovered service under the provisions of WAC
				  182-501-0160.
11-14-075, recodified as §
												182-533-0385, filed 6/30/11,
						effective 7/1/11. Statutory Authority:
						RCW
						74.08.090,
						74.09.760 through
						74.09.910, and 2009 c 564 §
						1109. 10-12-010, § 388-533-0385, filed 5/21/10, effective 6/21/10.
						Statutory Authority:
						RCW
						74.04.050,
						74.08.090,
						74.09.530, and
						74.09.700. 06-24-036, §
						388-533-0385, filed 11/30/06, effective 1/1/07. Statutory Authority:
						RCW
						74.08.090,
						74.09.760 through
						74.09.910. 04-13-049, §
						388-533-0385, filed 6/10/04, effective
						7/11/04.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-533 - Maternity-related services › FIRST STEPS SERVICES FOR WOMEN AND INFANTS › Section 182-533-0386 - Infant case management - Payment

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency must pay for the
				  covered infant case management (ICM) services described in WAC
				  182-533-0380 on a fee-for-service
				  basis subject to the following requirements.
ICM services must be:
(a) Provided to a client who meets the
				  eligibility requirements in WAC
				  182-533-0370.
(b) Provided by a person who meets the
				  criteria established in WAC
				  182-533-0375.
(c) Provided according to the agency's
				  current billing instructions .
(d)
				  Documented in the infant's and/or the parent's record or chart.
(e) Billed using:
(i) The eligible infant's medic-aid
				  agency-assigned client identification number;
(ii) The appropriate procedure codes and
				  modifiers identified in the agency's current billing instructions ;
				  and
(iii) The medicaid
				  agency-assigned MSS/ICM provider number.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-533 - Maternity-related services › FIRST STEPS SERVICES FOR WOMEN AND INFANTS › Section 182-533-0390 - Childbirth education (CBE) classes

Current through Register Vol. 24-14, July 15, 2024
(1) Purpose. The
				  purpose of childbirth education (CBE) classes is to help prepare the client and
				  the client's support person(s):
(a) For the
				  physiological, emotional, and psychological changes experienced during and
				  after pregnancy;
(b) To develop
				  self-advocacy skills;
(c) To
				  increase knowledge about and access to local community resources;
(d) To improve parenting skills;
				  and
(e) To improve the likelihood
				  of positive birth outcomes.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-533 - Maternity-related services › OTHER MATERNITY AND INFANT SERVICES › Section 182-533-0400 - Maternity care and newborn delivery

Current through Register Vol. 24-14, July 15, 2024
(1) The following definitions and
				  abbreviations and those found in chapter 182-500 WAC apply to this chapter.
(a)
"Birthing center"
means a
				  specialized facility licensed as a childbirth center by the department of
				  health (DOH) under chapter 246-349 WAC.
(b)
"Bundled services"
means
				  services integral to the major procedure that are included in the fee for the
				  major procedure. Under this chapter, certain services which are customarily
				  bundled must be billed separately (unbundled) when the services are provided by
				  different providers.
(c)
"Facility fee"
means the portion of the medicaid agency's payment
				  for the hospital or birthing center charges.
This does not include the agency's payment for the
					 professional fee.
(d)
"Global fee"
means the fee the agency pays for total obstetrical
				  care. Total obstetrical care includes all bundled antepartum care, delivery
				  services and postpartum care.
(e)
"High-risk"
pregnancy means any pregnancy that poses a significant
				  risk of a poor birth outcome.
(f)
"Professional fee"
means the portion of the agency's payment for
				  services that rely on the provider's professional skill or training, or the
				  part of the reimbursement that recognizes the provider's cognitive skill. (See
				  WAC
				  182-531-1850
				  for reimbursement methodology.)
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-533 - Maternity-related services › OTHER MATERNITY AND INFANT SERVICES › Section 182-533-0600 - Planned home births and births in birthing centers

Current through Register Vol. 24-14, July 15, 2024
(1)
Client eligibility.
The
				  medicaid agency covers planned home births and births in birthing centers for
				  clients who choose to give birth at home or in an agency-approved birthing
				  center and:
(a) Are eligible for the
				  alternative benefit package under WAC
				  182-501-0060,
				  categorically needy or medically needy scope of care under WAC
				  182-533-0400(2);
(b) Have an agency-approved medical provider
				  who has accepted responsibility for the planned home birth or birth in birthing
				  center under this section;
(c) Are
				  expected to deliver the child vaginally and without complication (i.e., with a
				  low risk of adverse birth outcome); and
(d) Pass the agency's risk screening
				  criteria. The agency provides these risk-screening criteria to qualified
				  medical services providers.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-533 - Maternity-related services › SUBSTANCE-USING PREGNANT PEOPLE (SUPP) SERVICES › Section 182-533-0701 - Substance-using pregnant people (SUPP) program-Purpose

Current through Register Vol. 24-14, July 15, 2024
The substance-using pregnant people (SUPP) program provides
					 immediate access to medical care in a hospital setting to substance-using or
					 substance-dependent pregnant people and their fetuses. The purpose of the
					 immediate access to medical care is to reduce harm to and improve birth
					 outcomes for birthing parents and their fetuses by preventing obstetric and
					 prenatal complications related to substance use disorder.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-533 - Maternity-related services › SUBSTANCE-USING PREGNANT PEOPLE (SUPP) SERVICES › Section 182-533-0710 - Substance-using pregnant people (SUPP) program-Client eligibility

Current through Register Vol. 24-14, July 15, 2024
(1) To be eligible
				  for the substance-using pregnant people (SUPP) program, a person must be:
(a) Pregnant; and
(b) Eligible for medicaid.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-533 - Maternity-related services › SUBSTANCE-USING PREGNANT PEOPLE (SUPP) SERVICES › Section 182-533-0720 - Substance-using pregnant people (SUPP) program-Provider requirements

Current through Register Vol. 24-14, July 15, 2024
(1) The agency pays
				  only those providers who:
(a) Have been
				  approved by the agency to provide substance-using pregnant people (SUPP)
				  program services;
(b) Have been
				  licensed and certified as a behavioral health agency by the department of
				  health (DOH) under chapter 246-341 WAC;
(c) Meet the department of health hospital
				  licensing regulations in chapter 246-320 WAC; and
(d) Meet the general provider requirements in
				  chapter 182-502 WAC.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-533 - Maternity-related services › SUBSTANCE-USING PREGNANT PEOPLE (SUPP) SERVICES › Section 182-533-0730 - Substance-using pregnant people (SUPP) program-Covered services

Current through Register Vol. 24-14, July 15, 2024
(1) The agency pays
				  for the following covered services for a pregnant client and their fetus under
				  the substance-using pregnant people (SUPP) program:
(a) Primary acute withdrawal management and
				  medical stabilization;
(b)
				  Secondary subacute withdrawal management and medical stabilization;
				  and
(c) Rehabilitation treatment
				  and services as determined by the provider.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-534 - Early and periodic screening, diagnosis and treatment (EPSDT) › Section 182-534-0100 - EPSDT

Current through Register Vol. 24-14, July 15, 2024
(1) Persons who are
				eligible for medicaid are eligible for coverage through the early and periodic
				screening, diagnosis, and treatment (EPSDT) program up through the day before
				their twenty-first birthday.
(2)
				Access and services for EPSDT are governed by federal rules at 42 C.F.R., Part
				441, Subpart B which were in effect as of January 1, 1998.
(a) The standard for coverage for EPSDT is
				that the services, treatment or other measures are:
(i) Medically necessary;
(ii) Safe and effective; and
(iii) Not experimental.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-534 - Early and periodic screening, diagnosis and treatment (EPSDT) › Section 182-534-0200 - Enhanced payments for EPSDT screens for children in out-of-home placement

Current through Register Vol. 24-14, July 15, 2024
The medicaid agency pays providers an enhanced fee for Early
				  and Periodic Screening, Diagnostic, and Treatment (EPSDT) screens provided to
				  children in out-of-home placement. See the agency's EPSDT provider guide for
				  specific billing code requirements, and see the agency's fee schedule for the
				  fee.
(1)For the purposes of this
				section, out-of-home placement means temporary, twenty-four hour per day,
				substitute care for a child:
(a)Placed away
				from the child's parents or guardians in licensed, paid, out-of-home care;
				and
(b) For whom the department of
				social and health services or a licensed or certified child placing agency has
				placement and care responsibility.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-535 - Dental-related services › GENERAL › Section 182-535-1060 - Client eligibility

Current through Register Vol. 24-14, July 15, 2024
(1) Refer to WAC
				  182-501-0060
				  to see which apple health programs include dental-related services in their
				  benefit package.
(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.
(3) See WAC
				  182-507-0115
				  for rules for clients eligible under the alien emergency medical
				  program.
(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. 12-09-081, §
												182-535-1060, filed 4/17/12,
						effective 5/18/12. 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. 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.
						1396 d(a),
						42 C.F.R.
						440.100 and
						440.225. 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 USC
						1396 d(a), C.F.R. 440.100 and 440.225.
						99-07-023, § 388-535-1060, filed 3/10/99, effective
						4/10/99.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-535 - Dental-related services › GENERAL › Section 182-535-1070 - Dental-related services-Provider information

Current through Register Vol. 24-14, July 15, 2024
(1) The following providers are eligible to
				  enroll with the medicaid agency to furnish and bill for dental-related services
				  provided to eligible clients:
(a) Persons
				  currently licensed by the state of Washington to:
(i) Practice dentistry or specialties of
				  dentistry.
(ii) Practice as dental
				  hygienists.
(iii) Practice as
				  denturists.
(iv) Practice
				  anesthesia by:
(A) Providing conscious
				  sedation with parenteral or multiple oral agents, deep sedation, or general
				  anesthesia as an anesthesiologist or dental anesthesiologist;
(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
(C) Providing conscious sedation with
				  parenteral or multiple oral agents as a dentist, when the dentist has a
				  conscious sedation permit issued by the department of health (DOH) that is
				  current at the time the billed service(s) is provided; or
(D) Providing deep sedation or general
				  anesthesia as a dentist when the dentist has a general anesthesia permit issued
				  by DOH that is current at the time the billed service(s) is provided.
(v) Practice medicine and
				  osteopathy for:
(A) Oral surgery procedures;
				  or
(B) Providing fluoride varnish
				  under EPSDT.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-535 - Dental-related services › GENERAL › Section 182-535-1079 - Dental-related services-General

Current through Register Vol. 24-14, July 15, 2024
(1) Clients
				  described in WAC
				  182-535-1060 are eligible to
				  receive the dental-related services described in this chapter, subject to
				  coverage limitations, restrictions, and client age requirements identified for
				  a specific service. The medic-aid agency pays for dental-related services and
				  procedures provided to eligible clients when the services and procedures:
(a) Are part of the client's dental benefit
				  package;
(b) Are within the scope
				  of an eligible client's Washington apple health program;
(c) Are medically necessary;
(d) Meet the agency's authorization
				  requirements, if any;
(e) Are
				  documented in the client's dental record in accordance with chapter 182-502 WAC
				  and meet the department of health's requirements in WAC
				  246-817-305 and
				  246-817-310;
(f) Are within accepted dental or medical
				  practice standards;
(g) Are
				  consistent with a diagnosis of a dental disease or dental condition;
(h) Are reasonable in amount and duration of
				  care, treatment, or service; and
(i) Are listed as covered in the agency's
				  rules and published billing instructions and fee schedules.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-535 - Dental-related services › GENERAL › Section 182-535-1080 - Covered-Diagnostic

Current through Register Vol. 24-14, July 15, 2024
Clients described in WAC
					 182-535-1060
					 are eligible to receive the dental-related diagnostic services listed in this
					 section, subject to coverage limitations, restrictions, and client age
					 requirements identified for a specific service.
(1)
Clinical oral evaluations.
The medicaid agency covers the following oral health evaluations and
				  assessments, per client, per provider or clinic:
(a) Periodic oral evaluations as defined in
				  WAC 182535-1050, once every six months. Six months must elapse between the
				  comprehensive oral evaluation and the first periodic oral evaluation.
(b) Limited oral evaluations as defined in
				  WAC 182535-1050, only when the provider performing the limited oral evaluation
				  is not providing routine scheduled dental services for the client on the same
				  day. The limited oral evaluation:
(i) Must be
				  to evaluate the client for a:
(A) Specific
				  dental problem or oral health complaint;
(B) Dental emergency; or
(C) Referral for other treatment.
(ii) When performed by a
				  denturist, is limited to the initial examination appointment. The agency does
				  not cover any additional limited examination by a denturist for the same client
				  until three months after a removable prosthesis has been delivered.
(c) Comprehensive oral evaluations
				  as defined in WAC
				  182-535-1050, once
				  per client, per provider or clinic, as an initial examination. The agency
				  covers an additional comprehensive oral evaluation if the client has not been
				  treated by the same provider or clinic within the past five years.
(d) Limited visual oral assessments as
				  defined in WAC
				  182-535-1050, two
				  times per client, per provider in a twelvemonth period only when the assessment
				  is:
(i) Not performed in conjunction with
				  other clinical oral evaluation services; and
(ii) Performed by a licensed dentist or
				  dental hygienist to determine the need for sealants or fluoride treatment or
				  when triage services are provided in settings other than dental offices or
				  clinics.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-535 - Dental-related services › GENERAL › Section 182-535-1082 - Covered-Preventive services

Current through Register Vol. 24-14, July 15, 2024
Clients described in WAC
					 182-535-1060
					 are eligible for the dental-related preventive services listed in this section,
					 subject to coverage limitations and client-age requirements identified for a
					 specific service.
(1)
Prophylaxis.
The medicaid agency covers prophylaxis as follows.
				  Prophylaxis:
(a) Includes scaling and
				  polishing procedures to remove coronal plaque, calculus, and stains when
				  performed on tooth structures and implants.
(b) Is limited to once every:
(i) Six months for clients:
(A) Age 18 and younger; or
(B) Of any age residing in an alternate
				  living facility or nursing facility;
(ii) Twelve months for clients age 19 and
				  older.
(c) Is reimbursed
				  according to (b) of this subsection when the service is performed:
(i) At least six months after periodontal
				  scaling and root planing, or periodontal maintenance services, for clients:
(A) Age 13 through 18; or
(B) Of any age residing in an alternate
				  living facility or nursing facility; or
(ii) At least 12 months after periodontal
				  scaling and root planing, periodontal maintenance services, for clients age 19
				  and older.
(d) Is not
				  reimbursed separately when performed on the same date of service as periodontal
				  scaling and root planing, periodontal maintenance, gingivectomy, gingivoplasty,
				  or scaling in the presence of generalized moderate or severe gingival
				  inflammation.
(e) Is covered for
				  clients of the developmental disabilities administration of the department of
				  social and health services (DSHS) according to (a), (c), and (d) of this
				  subsection and WAC
				  182-535-1099.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-535 - Dental-related services › GENERAL › Section 182-535-1084 - Dental-related services-Covered-Restorative services

Current through Register Vol. 24-14, July 15, 2024
Clients described in WAC 182535-1060 are eligible for the
					 dental-related restorative services listed in this section, subject to coverage
					 limitations, restrictions, and client age requirements identified for a
					 specific service.
(1)
Amalgam,
				  resin, and glass ionomer restorations for primary and permanent teeth.
The medicaid agency considers:
(a) Tooth
				  preparation, acid etching, all adhesives (including bonding agents), liners and
				  bases, indirect and direct pulp capping, polishing, and curing as part of the
				  restoration.
(b) Occlusal
				  adjustment of either the restored tooth or the opposing tooth or teeth as part
				  of the restoration.
(c)
				  Restorations placed within six months of a crown preparation by the same
				  provider or clinic to be included in the payment for the crown.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-535 - Dental-related services › GENERAL › Section 182-535-1086 - Dental-related services-Covered-Endodontic services

Current through Register Vol. 24-14, July 15, 2024
Clients described in WAC
					 182-535-1060 are eligible to
					 receive the dental-related endodontic services listed in this section, subject
					 to coverage limitations, restrictions, and client age requirements identified
					 for a specific service.
(1)
Pulp
				  capping.
The medicaid agency considers pulp capping to be included in
				  the payment for the restoration.
(2)
Pulpotomy.
The agency
				  covers:
(a) Therapeutic pulpotomy on primary
				  teeth only for clients age twenty and younger.
(b) Pulpal debridement on permanent teeth
				  only, excluding teeth one, sixteen, seventeen, and thirty-two. The agency does
				  not pay for pulpal debridement when performed with palliative treatment of
				  dental pain or when performed on the same day as endodontic
				  treatment.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-535 - Dental-related services › GENERAL › Section 182-535-1088 - Dental-related services-Covered-Periodontic services

Current through Register Vol. 24-14, July 15, 2024
Clients described in WAC
					 182-535-1060 are eligible to
					 receive the dental-related periodontic services listed in this section, subject
					 to coverage limitations, restrictions, and client-age requirements identified
					 for a specified service.
(1)
Surgical periodontal services.
The medicaid agency covers the
				  following surgical periodontal services, including all postoperative care:
(a) Gingivectomy/gingivoplasty (does not
				  include distal wedge procedures on erupting molars) only on a case-by-case
				  basis and when prior authorized and only for clients age 20 and younger;
				  and
(b) Gingivectomy/gingivoplasty
				  (does not include distal wedge procedures on erupting molars) for clients of
				  the developmental disabilities administration of the department of social and
				  health services (DSHS) according to WAC
				  182-535-1099.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-535 - Dental-related services › GENERAL › Section 182-535-1090 - Dental-related services-Covered-Prosthodontics (removable)

Current through Register Vol. 24-14, July 15, 2024
Clients described in WAC
					 182-535-1060
					 are eligible to receive the prosthodontics (removable) and related services,
					 subject to the coverage limitations, restrictions, and clientage requirements
					 identified for a specific service.
(1)
Prosthodontics.
The medicaid agency requires prior authorization
				  for removable prosthodontic and prosthodontic-related procedures, except as
				  otherwise noted in this section. Prior authorization requests must meet the
				  criteria in WAC
				  182-535-1220.
				  In addition, the agency requires the dental provider to submit:
(a) Appropriate and diagnostic radiographs of
				  all remaining teeth.
(b) A dental
				  record which identifies:
(i) All missing
				  teeth for both arches;
(ii) Teeth
				  that are to be extracted; and
(iii)
				  Dental restorative and periodontal services completed on all remaining teeth in
				  the arch(es) being requested.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-535 - Dental-related services › GENERAL › Section 182-535-1092 - Dental-related services-Covered-Maxillofacial prosthetic services

Current through Register Vol. 24-14, July 15, 2024
Clients described in WAC
					 182-535-1060 are eligible to
					 receive the maxillofacial prosthetic services listed in this section, subject
					 to the following:
(1) Maxillofacial
				  prosthetics are covered on a case-by-case basis and when prior authorized;
				  and
(2) The medicaid agency must
				  preapprove a provider qualified to furnish maxillofacial prosthetics.
Statutory Authority:
						RCW
						41.05.021. 12-09-081, §
												182-535-1092, filed 4/17/12,
						effective 5/18/12. 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. 07-06-042, §
						388-535-1092, filed 3/1/07, effective
						4/1/07.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-535 - Dental-related services › GENERAL › Section 182-535-1096 - Dental-related services - Covered - Orthodontic services

Current through Register Vol. 24-14, July 15, 2024
(1) The agency covers orthodontic services,
				  subject to the coverage limitations listed, for clients twenty years of age and
				  younger, according to chapter 182-535A WAC.
(2) The agency does not cover orthodontic
				  services for clients twenty-one years of age and older.
Statutory Authority:
						RCW
						41.05.021. 12-09-081, §
												182-535-1096, filed 4/17/12,
						effective 5/18/12. 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. 07-06-042, §
						388-535-1096, filed 3/1/07, effective
						4/1/07.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-535 - Dental-related services › GENERAL › Section 182-535-1098 - Covered-Adjunctive general services

Current through Register Vol. 24-14, July 15, 2024
Clients described in WAC
					 182-535-1060 are eligible to
					 receive the adjunctive general services listed in this section, subject to
					 coverage limitations, restrictions, and client-age requirements identified for
					 a specific service.
(1)
Adjunctive general services.
The medicaid agency:
(a) Covers palliative (emergency) treatment,
				  not to include pupal debridement (see WAC
				  182-535-1086(2)(b)),
				  for treatment of dental pain, limited to once per day, per client, as follows:
(i) The treatment must occur during limited
				  evaluation appointments;
(ii) A
				  comprehensive description of the diagnosis and services provided must be
				  documented in the client's record; and
(iii) Appropriate radiographs must be in the
				  client's record supporting the medical necessity of the treatment.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-535 - Dental-related services › GENERAL › Section 182-535-1099 - Dental-related services for clients of the developmental disabilities administration of the department of social and health services

Current through Register Vol. 24-14, July 15, 2024
Subject to coverage limitations and restrictions identified
					 for a specific service, the medicaid agency pays for the additional
					 dental-related services listed in this section that are provided to clients of
					 the developmental disabilities administration of the department of social and
					 health services (DSHS), regardless of age.
(1)
Preventive services.
The
				  agency covers:
(a) Periodic oral evaluations
				  once every four months per client, per provider.
(b) Prophylaxis once every four
				  months.
(c) Periodontal maintenance
				  once every six months (see subsection (3) of this section for limitations on
				  periodontal scaling and root planing).
(d) Topical fluoride varnish, rinse, foam or
				  gel, once every four months, per client, per provider or clinic.
(e) Sealants (see WAC
				  182-535-1082
				  for sealant coverage):
(i) Only when used on
				  the occlusal surfaces of:
(A) Primary teeth A,
				  B, I, J, K, L, S, and T; or
(B)
				  Permanent teeth two, three, four, five, twelve, thirteen, fourteen, fifteen,
				  eighteen, nineteen, twenty, twenty-one, twenty-eight, twenty-nine, thirty, and
				  thirty-one.
(ii) Once
				  per tooth in a two-year period.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-535 - Dental-related services › GENERAL › Section 182-535-1100 - Dental-related services-Not covered

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				  agency does not cover the following under the dental program:
(a) The dental-related services described in
				  subsection (2) of this section unless the services are covered under the early
				  periodic screening, diagnostic, and treatment (EPSDT) program. When EPSDT
				  applies, the agency evaluates a noncovered service, equipment, or supply
				  according to the process in WAC
				  182-501-0165 to determine if it
				  is medically necessary, safe, effective, and not experimental.
(b) Any service specifically excluded by
				  statute.
(c) More costly services
				  when less costly, equally effective services as determined by the agency are
				  available.
(d) Services,
				  procedures, treatment, devices, drugs, or application of associated services:
(i) That the agency or the Centers for
				  Medicare and Medicaid Services (CMS) considers investigative or experimental on
				  the date the services were provided.
(ii) That are not listed as covered in one or
				  both of the following:
(A) Washington
				  Administrative Code (WAC).
(B) The
				  agency's current published documents.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-535 - Dental-related services › GENERAL › Section 182-535-1220 - Obtaining prior authorization for dental-related services

Current through Register Vol. 24-14, July 15, 2024
(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 182535-1080(2));
(b) Photographs; and
(c) Any other information as determined by
				  the agency.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-535 - Dental-related services › ABCD DENTAL PROGRAM › Section 182-535-1245 - Access to baby and child dentistry (ABCD) program

Current through Register Vol. 24-14, July 15, 2024
The access to baby and child dentistry (ABCD) program
					 increases access to dental services for certain medicaid-eligible
					 clients.
(1) A client is eligible for
				  the ABCD program if the client is:
(a)
				  Eligible for one of the following medical assistance programs:
(i) Categorically needy program
				  (CNP);
(ii) Limited casualty
				  program-medically needy program (LCP-MNP);
(iii) Children's health program; or
(iv) State children's health insurance
				  program (SCHIP); and
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-535 - Dental-related services › ABCD DENTAL PROGRAM › Section 182-535-1270 - Oral health connections pilot project

Current through Register Vol. 24-14, July 15, 2024
(1) The oral health connections pilot project
				  is effective for dates of service from January 1, 2019, through December 31,
				  2023.
(2) The purpose of the oral
				  health connections pilot project is to test the effect that enhanced oral
				  health services have on the overall health of diabetic or pregnant medicaid
				  clients receiving services in Cowlitz, Spokane, and Thurston
				  counties.
(3) To be eligible for
				  the oral health connections pilot project, a client must:
(a) Be diabetic and age 21 or older;
				  or
(b) Be pregnant and 16 years of
				  age or older; and
(c) Be receiving
				  services under subsection (6) of this section in Cowlitz, Spokane, or Thurston
				  counties; and
(d) Be referred by a
				  nondental primary health care provider, managed care organization, or a
				  designated community organization to a qualified oral health connections pilot
				  project dental provider. For the purposes of this section, a designated
				  community organization is defined as an auxiliary group or groups that partner
				  with the agency and Arcora foundation to implement the oral health connections
				  pilot project or provide an attestation showing the client has been diagnosed
				  with diabetes or pregnancy, or both.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-535 - Dental-related services › PAYMENT › Section 182-535-1350 - Payment methodology for dental-related services

Current through Register Vol. 24-14, July 15, 2024
The agency uses the description of dental services
					 described in the American Dental Association's Current Dental Terminology
					 (CDT), and the American Medical Association's Physician's Current Procedural
					 Terminology (CPT).
(1) For covered
				  dental-related services provided to eligible clients, the agency pays dentists
				  and other eligible providers on a fee-for-service or contractual basis, subject
				  to the exceptions and restrictions listed under WAC
				  182-535-1100
				  and
				  182-535-1400.
(2) The agency sets maximum allowable fees
				  for dental services as follows:
(a) The
				  agency's historical reimbursement rates for various procedures are compared to
				  usual and customary charges.
(b)
				  The agency consults with representatives of the provider community to identify
				  program areas and concerns that need to be addressed.
(c) The agency consults with dental experts
				  and public health professionals to identify and prioritize dental services and
				  procedures for their effectiveness in improving or promoting dental
				  health.
(d) Legislatively
				  authorized vendor rate increases and/or earmarked appropriations for 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 dental health.
(f) Budget-neutral rate adjustments are made
				  as appropriate based on the agency's evaluation of utilization trends,
				  effectiveness of interventions, and access issues.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-535 - Dental-related services › PAYMENT › Section 182-535-1400 - Payment for dental-related services

Current through Register Vol. 24-14, July 15, 2024
(1)
				  The agency considers that a provider who furnishes covered dental services to
				  an eligible client has accepted the agency's rules and fees.
(2) Participating providers must bill the
				  agency their usual and customary fees.
(3) Payment for dental services is based on
				  the agency's schedule of maximum allowances. Fees listed in the agency's fee
				  schedule are the maximum allowable fees.
(4) The agency pays the provider the lesser
				  of the billed charge (usual and customary fee) or the agency's maximum
				  allowable fee.
(5) The agency pays
				  dental general anesthesia services for eligible clients as follows:
(a) Fifteen-minute increments are billed as
				  one unit of time. When a dental procedure requires multiple fifteen-minute
				  units and there is a remainder (less than fifteen minutes), the remainder is
				  considered one unit.
(b) When
				  billing for anesthesia, the provider must show the actual beginning and ending
				  times in the client's medical record. 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 safely placed under
				  postoperative supervision).
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-535 - Dental-related services › PAYMENT › Section 182-535-1450 - Payment for denture laboratory services

Current through Register Vol. 24-14, July 15, 2024
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. 12-09-081, §
												182-535-1450, filed 4/17/12,
						effective 5/18/12. 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. 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.
						1396 d(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
						1396 d(a), C.F.R. 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.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-535 - Dental-related services › PAYMENT › Section 182-535-1500 - Payment for dental-related hospital services

Current through Register Vol. 24-14, July 15, 2024
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. 12-09-081, §
												182-535-1500, filed 4/17/12,
						effective 5/18/12. 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.
						1396 d(a),
						42 C.F.R.
						440.100 and
						440.225. 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 USC
						1396 d(a), C.F.R. 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. and74.08.090 . 96-01-006 (Order
						3931), § 388-535-1500, filed 12/6/95, effective
						1/6/96.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-535 - Dental-related services › PAYMENT › Section 182-535-1550 - Payment for dental care provided out-of-state

Current through Register Vol. 24-14, July 15, 2024
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.
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. 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.
						1396 d(a),
						42 C.F.R.
						440.100 and
						440.225. 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 USC
						1396 d(a), C.F.R. 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.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-535A - Orthodontic services › Section 182-535A-0020 - Client eligibility

Current through Register Vol. 24-14, July 15, 2024
(1) Subject to
				the limitations of this chapter, the medicaid agency covers medically necessary
				orthodontic treatment and orthodontic-related services for severe handicapping
				malocclusions, cra-niofacial anomalies, or cleft lip or palate, for eligible
				clients through age twenty. Refer to WAC
				182-501-0060
				to see which Washington apple health programs include orthodontic services in
				their benefit package.
(2) Eligible
				clients may receive the same orthodontic treatment and orthodontic-related
				services in recognized out-of-state bordering cities on the same basis as if
				provided instate. See WAC
				182-501-0175.
(3) Eligible clients may receive the same
				orthodontic treatment and orthodontic-related services for continued
				orthodontic treatment when originally rendered by a non-medicaid or
				out-of-state provider as follows:
(a) The
				provider must submit the initial orthodontic case study and treatment plan
				records with the request for continued treatment.
(b) The agency evaluates the initial
				orthodontic case study and treatment plan to determine if the client met the
				agency's orthodontic criteria per WAC
				182-535A-0040(1)
				through (3).
(c) The agency determines continued treatment
				duration based on the client's current orthodontic conditions.
(d) The agency does not cover continued
				treatment if the client's initial condition did not meet the agency's criteria
				for the initial orthodontic treatment. The agency pays a deband and retainer
				fee if the client does not meet the initial orthodontic treatment
				criteria.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-535A - Orthodontic services › Section 182-535A-0030 - Orthodontic treatment and orthodontic-related services-Provider eligibility

Current through Register Vol. 24-14, July 15, 2024
The following provider types may furnish and be paid for
				  providing covered orthodontic treatment and orthodontic-related services to
				  eligible medical assistance clients:
(1) Orthodontists;
(2) Pediatric dentists;
(3) General dentists; and
(4) Agency-recognized craniofacial teams or
				other orthodontic specialists approved by the agency.
11-14-075, recodified as §
											182-535A-0030, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.04.050,
					 74.08.090. 08-17-009, §
					 388-535A-0030, filed 8/7/08, effective 9/7/08. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.520 and
					 74.09.035,
					 74.09.500. 05-01-064, §
					 388-535A-0030, filed 12/8/04, effective 1/8/05. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.035,
					 74.09.520,
					 74.09.500,
					 42 U.S.C.
					 1396 d(a), C.F.R. 440.100 and 225. 02-01-050,
					 § 388-535A-0030, filed 12/11/01, effective
					 1/11/02.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-535A - Orthodontic services › Section 182-535A-0040 - Orthodontic treatment and orthodontic-related services-Covered, noncovered, and limitations to coverage

Current through Register Vol. 24-14, July 15, 2024
Orthodontic treatment and orthodontic-related services
				  require prior authorization.
(1) The
				medicaid agency covers orthodontic treatment and orthodontic-related services
				for a client who has one of the medical conditions listed in (a) and (b) of
				this subsection. Treatment and follow-up care must be performed by a provider
				who is part of a craniofacial team that includes, but is not limited to, a
				general or pediatric dentist, orthodontist, and an oral maxillofacial surgeon
				or specialist.
(a) Cleft lip and palate, cleft
				palate, or cleft lip.
(b) The
				following craniofacial anomalies including, but not limited to:
(i) Hemifacial microsomia;
(ii) Craniosynostosis syndromes;
(iii) Cleidocranial dental
				dysplasia;
(iv)
				Arthrogryposis;
(v) Marfan
				syndrome;
(vi) Treacher Collins
				syndrome;
(vii) Ectodermal
				dysplasia; or
(viii)
				Achondroplasia.