HCA Provider Alerts: 3/28/17
Washington State Health Care Authority (HCA) has issued two provider alerts regarding prior authorization for four or more extractions making a patient edentulous and Orthognathic prior authorization requests.
Prior authorization for four or more extractions making a patient edentulous
Previously, the Health Care Authority (HCA) processed authorization requests for extractions and approved them with the expectation that our providers would bill surgical and simple extractions as necessary. However, our Data Analytics and Review Unit found surgical extractions were billed when simple extractions would have been a less costly and equally effective treatment. As a result of these findings, we are reminding you that our dental consultants review these requests for medical necessity and approve or deny according to the criteria listed in WAC 182-501-0165.
HCA requires you to submit a prior authorization requests for simple and surgical extractions with the appropriate CDT code along with the tooth number(s) on the General Information for Authorization (HCA 13-835) form. If the authorization request for surgical extractions is denied, you may submit a prior authorization request for simple extractions. If you feel a surgical extraction would be more appropriate, resubmit the prior authorization request indicating why surgical extractions are more appropriate. You must include the documented medical justification with the request.
Note: If you have been approved for simple extractions, but decide during the procedure that a tooth requires surgical extraction, you may request a retroactive authorization by submitting records that indicate the medical justification for performing a surgical extraction instead of a simple extraction.
Orthognathic prior authorization requests
When initial orthodontic prior authorization requests indicate orthognathic surgery may be needed toward the end of the orthodontic treatment, the Health Care Authority (HCA) requires the prior authorization request to include a short letter from an oral surgeon indicating a commitment to treat the client if surgery becomes medically necessary. If the initial orthodontic request does not include the commitment letter, HCA will reject the request with instructions to resubmit the request with a commitment letter.
Six to eight weeks prior to the anticipated orthognathic surgery date, per the orthodontic treatment plan, the oral surgeon who committed to treat the client will evaluate the client to determine if surgery is medically necessary. If the oral surgeon determines that surgery is medically necessary, the surgeon must submit a prior authorization request to HCA that includes documentation explaining the anticipated surgical intervention(s), current facial and intraoral photos, a cephalometric x-ray, procedure codes that will be billed, and the expected date of surgery. HCA will reject the surgical request if it is submitted prior to the six to eight week timeframe.