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Washington State Dental Association

Medicaid Policy Updates Announced

Attention Medicaid Providers: There have been recent policy updates in Chapter 182-535 WAC which will affect claims with dates of service on and after May 1, 2014. Below, is a list of the major updates. Please contact Emily Lovell at should you have any questions.

Anesthesia – Removed general anesthesia for clients 21 years of age and older from noncovered list; prior authorization is required.

Crowns – Changed coverage for crowns (single restorations only) for permanent anterior teeth for clients 12 through 20 years of age to clients 15 through 20 years of age. The agency does not cover permanent anterior crowns for clients 0 through 14 years of age.
Extractions and surgical extractions – Prior authorization is required when one of the following applies:
  • Extractions of four or more teeth over a six-month period, per provider, results in the client becoming edentulous in the maxillary arch or mandibular arch 
  • Tooth number is not able to be determined 
*Please note the new requirement for prior authorization is only required when extractions of four or more teeth result in the client becoming edentulous. This rule does not require prior authorization when a dentist pulls more than four teeth if the patient does not become edentulous in either arch. In the case of legitimate dental emergencies, more than four teeth can be pulled and authorization can be received after the fact. 

Nursing facility clients – Removed expedited prior authorization requirement for dental services for clients in a nursing facility
Oral hygiene instructions – Clarified what is included in oral hygiene instruction
Prior authorization requirement change – Prior authorization is now required for clients 20 years of age and younger, for CDT code D7280 surgical access of unerupted teeth. 

*Please note there was an error in the anesthesia rules for children that has been subsequently fixed. Prior authorization will not be required for general anesthesia for clients under the age of 20. Updated language will be shared with providers shortly. 
Tobacco cessation counseling – Removed from noncovered.  Added coverage for clients 18 years of age and older and pregnant women any age for the control and prevention of oral disease.

Topical fluoride treatment, now includes coverage for fluoride varnish for all ages with limits

Tooth chart (updated 2/14) – The agency has revised HCA 13-863 form,Tooth Chart.  Providers should begin using the updated tooth chart now.  Beginning June 1, 2014, the agency will reject prior authorization requests which are not accompanied by the revised HCA 13-863 form, Tooth Chart.  When requesting partial dentures, providers must answer the question on the form regarding whether all periodontal services have been completed on all remaining teeth.


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