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Washington State Dental Association

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.

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