New Form for Orthodontic Prior Authorization Requests
In order to correctly process prior authorization (PA) requests for orthodontic treatment, the Health Care Authority revised the Orthodontic Information form (HCA 13-666). Effective for dates of service on and after April 1, 2017, providers must use the updated Orthodontic Information form (HCA 13-666) for orthodontic treatment PA requests. HCA 13-666 must be submitted in addition to the General Information for Authorization form (HCA 13-835). The agency will reject all PA requests for orthodontic treatment that are not submitted on the revised form.
Part II, #3, of the updated form requires the provider to submit a colored photograph if the client has an overjet greater than 9mm with incompetent lips, or a reverse overjet greater than 3.5mm with reported masticatory and speech difficulties.
The updated form is available for download on the agency’s Forms & Publications web page and can be used immediately.