Chapter 182-535A WAC

Last Update: 5/7/19

ORTHODONTIC SERVICES

WAC Sections

182-535A-0010Definitions.
182-535A-0020Client eligibility.
182-535A-0030Orthodontic treatment and orthodontic-related services—Provider eligibility.
182-535A-0040Orthodontic treatment and orthodontic-related services—Covered, noncovered, and limitations to coverage.
182-535A-0050Orthodontic treatment and orthodontic-related services—Authorization and prior authorization.
182-535A-0060Orthodontic treatment and orthodontic-related services—Payment.


182-535A-0010
Definitions.

The following definitions and those found in chapter 182-500 WAC apply to this chapter.
"Adolescent dentition" means teeth that are present after the loss of primary teeth and prior to the cessation of growth that affects orthodontic treatment.
"Appliance placement" means the application of orthodontic attachments to the teeth for the purpose of correcting dentofacial abnormalities.
"Cleft" means an opening or fissure involving the dentition and supporting structures, especially one occurring in utero. These can be:
(a) Cleft lip;
(b) Cleft palate (involving the roof of the mouth); or
(c) Facial clefts (e.g., macrostomia).
"Comprehensive full orthodontic treatment" means utilizing fixed orthodontic appliances for treatment of adolescent dentition leading to the improvement of a client's severe handicapping craniofacial dysfunction and/or dentofacial deformity, including anatomical and functional relationships.
"Craniofacial anomalies" means abnormalities of the head and face, either congenital or acquired, involving disruption of the dentition and supporting structures.
"Craniofacial team" means a cleft palate/maxillofacial team or an American Cleft Palate Association-certified craniofacial team. These teams are responsible for the management (review, evaluation, and approval) of patients with cleft palate craniofacial anomalies to provide integrated management, promote parent-professional partnership, and make appropriate referrals to implement and coordinate treatment plans.
"Crossbite" means an abnormal relationship of a tooth or teeth to the opposing tooth or teeth, in which normal buccolingual or labiolingual relations are reversed.
"Dental dysplasia" means an abnormality in the development of the teeth.
"Ectopic eruption" means a condition in which a tooth erupts in an abnormal position or is fifty percent blocked out of its normal alignment in the dental arch.
"EPSDT" means the agency's early and periodic screening, diagnostic, and treatment program for clients twenty years of age and younger as described in chapter 182-534 WAC.
"Hemifacial microsomia" means a developmental condition involving the first and second brachial arch. This creates an abnormality of the upper and lower jaw, ear, and associated structures (half or part of the face is smaller in size).
"Interceptive orthodontic treatment" means procedures to lessen the severity or future effects of a malformation and to affect or eliminate the cause. Such treatment may occur in the primary or transitional dentition and may include such procedures as the redirection of ectopically erupting teeth, correction of isolated dental cross-bite, or recovery of recent minor space loss where overall space is adequate.
"Limited orthodontic treatment" means orthodontic treatment with a limited objective, not involving the entire dentition. It may be directed only at the existing problem, or at only one aspect of a larger problem in which a decision is made to defer or forego more comprehensive therapy.
"Malocclusion" means improper alignment of biting or chewing surfaces of upper and lower teeth or abnormal relationship of the upper and lower dental arches.
"Maxillofacial" means relating to the jaws and face.
"Occlusion" means the relation of the upper and lower teeth when in functional contact during jaw movement.
"Orthodontics" means treatment involving the use of any appliance, in or out of the mouth, removable or fixed, or any surgical procedure designed to redirect teeth and surrounding tissues.
"Orthodontist" means a dentist who specializes in orthodontics, who is a graduate of a postgraduate program in orthodontics that is accredited by the American Dental Association, and who meets the licensure requirements of the department of health.
"Permanent dentition" means those teeth that succeed the primary teeth and the additional molars that erupt.
"Prepaid ambulatory health plan" or "PAHP" see WAC 182-538-050. For the purpose of this chapter, dental managed care contractors are considered PAHPs.
"Primary dentition" means teeth that develop and erupt first in order of time and are normally shed and replaced by permanent teeth.
"Transitional dentition" means the final phase from primary to permanent dentition, in which most primary teeth have been lost or are in the process of exfoliating and the permanent successors are erupting.
[Statutory Authority: RCW 41.05.021, 41.05.160 and 2017 3rd sp.s. c 1 § 213 (1)(c). WSR 19-09-058, § 182-535A-0010, filed 4/15/19, effective 7/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-20-097, § 182-535A-0010, filed 10/3/17, effective 11/3/17. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535A-0010, filed 3/25/14, effective 4/30/14. WSR 11-14-075, recodified as § 182-535A-0010, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 08-17-009, § 388-535A-0010, filed 8/7/08, effective 9/7/08. Statutory Authority: RCW 74.08.090, 74.09.520 and 74.09.035, 74.09.500. WSR 05-01-064, § 388-535A-0010, 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. 1396d(a), C.F.R. 440.100 and 225. WSR 02-01-050, § 388-535A-0010, filed 12/11/01, effective 1/11/02.]



182-535A-0020
Client eligibility.

(1) Subject to the limitations of this chapter, the medicaid agency covers medically necessary orthodontic treatment and orthodontic-related services for severe handicapping malocclusions, craniofacial 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) Clients enrolled in an agency-contracted managed care organization (MCO) or prepaid ambulatory health plan (PAHP) must receive their orthodontic services through that MCO or PAHP, except as described under WAC 182-538-095. Clients whose benefit package includes dental services are assigned a dental managed care plan. If a client is not eligible for a dental managed care plan, they receive services on a fee-for-service basis.
(a) All clients are eligible for dental managed care benefits with the exception of clients receiving apple health benefits under a state-only program.
(b) Clients eligible for dental managed care on a voluntary basis include:
(i) American Indian/Alaska native (AI/AN) clients; and
(ii) Clients who reside in a county that has only one MCO or PAHP.
(c) See WAC 182-538-060 for more details regarding managed care choice and assignment.
(d) If a client receiving orthodontic services through an MCO or PAHP chooses to transfer to another MCO or PAHP or to fee-for-service (FFS) during active orthodontic treatment, the MCO or PAHP that initiated the orthodontic treatment remains responsible for payment until completion of the orthodontic treatment.
(e) If an FFS client transfers to an MCO or PAHP during active orthodontic treatment, the MCO or PAHP assumes payment responsibility until completion of the orthodontic treatment.
(3) 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 in-state. See WAC 182-501-0175.
(4) Eligible clients may receive the same orthodontic treatment and orthodontic-related services for continued orthodontic treatment when originally rendered by a nonmedicaid 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.
[Statutory Authority: RCW 41.05.021, 41.05.160 and 2017 3rd sp.s. c 1 § 213 (1)(c). WSR 19-09-058, § 182-535A-0020, filed 4/15/19, effective 7/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-20-097, § 182-535A-0020, filed 10/3/17, effective 11/3/17. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535A-0020, filed 3/25/14, effective 4/30/14. WSR 11-14-075, recodified as § 182-535A-0020, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 08-17-009, § 388-535A-0020, filed 8/7/08, effective 9/7/08. Statutory Authority: RCW 74.08.090, 74.09.520 and 74.09.035, 74.09.500. WSR 05-01-064, § 388-535A-0020, 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. 1396d(a), C.F.R. 440.100 and 225. WSR 02-01-050, § 388-535A-0020, filed 12/11/01, effective 1/11/02.]



182-535A-0030
Orthodontic treatment and orthodontic-related services—Provider eligibility.

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.
[Statutory Authority: RCW 41.05.021, 41.05.160. WSR 16-10-064, § 182-535A-0030, filed 5/2/16, effective 6/2/16. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535A-0030, filed 3/25/14, effective 4/30/14. WSR 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. WSR 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. WSR 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. 1396d(a), C.F.R. 440.100 and 225. WSR 02-01-050, § 388-535A-0030, filed 12/11/01, effective 1/11/02.]



182-535A-0040
Orthodontic treatment and orthodontic-related servicesCovered, noncovered, and limitations to coverage.

Coverage and authorization of covered services is subject to the requirements and limitations in this chapter and other applicable WAC.
(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 only by an orthodontist or agency-recognized craniofacial team.
(a) Cleft lip and palate, cleft palate, or cleft lip with alveolar process involvement.
(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.
(2) The agency authorizes orthodontic treatment and orthodontic-related services when the following criteria are met:
(a) Severe malocclusions with a Washington Modified Handicapping Labiolingual Deviation (HLD) Index Score of twenty-five or higher as determined by the agency;
(b) The client has established caries control; and
(c) The client has established plaque control.
(3) The agency may cover orthodontic treatment for dental malocclusions other than those listed in subsections (1) and (2) of this section on a case-by-case basis and when prior authorized. The agency determines medical necessity based on documentation submitted by the provider.
(4) The agency does not cover the following orthodontic treatment or orthodontic-related services:
(a) Orthodontic treatment for cosmetic purposes;
(b) Orthodontic treatment that is not medically necessary (as defined in WAC 182-500-0070);
(c) Orthodontic treatment provided out-of-state, except as stated in WAC 182-501-0180 (see also WAC 182-501-0175 for medical care provided in bordering cities);
(d) Orthodontic treatment and orthodontic-related services that do not meet the requirements of this section or other applicable WAC; or
(e) Case studies that do not include a definitive orthodontic treatment plan.
(5) The agency covers the following orthodontic treatment and orthodontic-related services with prior authorization when medically necessary:
(a) Interceptive orthodontic treatment.
(b) Limited orthodontic treatment. The agency may approve limited orthodontic treatment for treatment of a single impacted tooth.
(c) Comprehensive full orthodontic treatment on adolescent dentition (see subsection (8)(a) of this section for information on limitation extensions).
(d) Case study.
(e) Other orthodontic treatment subject to review for medical necessity as determined by the agency.
(6) The agency covers the following orthodontic-related services with prior authorization when medically necessary:
(a) Clinical oral evaluations according to WAC 182-535-1080.
(b) Cephalometric films that are of diagnostic quality, dated, and labeled with the client's name.
(c) Replacement retainer.
(d) Orthodontic appliance removal as a stand-alone service only when:
(i) The client's appliance was placed by a different provider or dental clinic; and
(ii) The provider has not furnished any other orthodontic treatment or orthodontic-related services to the client.
(7) The treatment must meet industry standards and correct the medical issue. If treatment is discontinued prior to completion, or treatment objectives are not achieved, the provider must:
(a) Keep clear documentation in the client's record explaining why treatment was discontinued or not completed, or why treatment goals were not achieved.
(b) Notify the agency.
(8) The agency evaluates a request for orthodontic treatment or orthodontic-related services:
(a) That are in excess of the limitations or restrictions listed in this section, according to WAC 182-501-0169; and
(b) That are listed as noncovered according to WAC 182-501-0160.
(9) The agency reviews requests for orthodontic treatment or orthodontic-related services for clients who are eligible for services under the EPSDT program according to the provisions of WAC 182-534-0100.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-11-028, § 182-535A-0040, filed 5/7/19, effective 7/1/19; WSR 17-20-097, § 182-535A-0040, filed 10/3/17, effective 11/3/17; WSR 16-10-064, § 182-535A-0040, filed 5/2/16, effective 6/2/16. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535A-0040, filed 3/25/14, effective 4/30/14. WSR 11-14-075, recodified as § 182-535A-0040, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 08-17-009, § 388-535A-0040, filed 8/7/08, effective 9/7/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-535A-0040, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.520 and 74.09.035, 74.09.500. WSR 05-01-064, § 388-535A-0040, 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. 1396d(a), C.F.R. 440.100 and 225. WSR 02-01-050, § 388-535A-0040, filed 12/11/01, effective 1/11/02.]



182-535A-0050
Orthodontic treatment and orthodontic-related services—Authorization and prior authorization.

(1) When the medicaid agency authorizes an interceptive orthodontic treatment, limited orthodontic treatment, full orthodontic treatment, or orthodontic-related services for a client, including a client eligible for services under the EPSDT program, that authorization indicates only that the specific service is medically necessary; authorization is not a guarantee of payment. The client must be eligible for the covered service at the time the service is provided.
(2) For orthodontic treatment of a client with cleft lip, cleft palate, or other craniofacial anomaly, prior authorization is not required if the client is being treated by an agency-recognized craniofacial team, or an orthodontic specialist who has been approved by the agency to treat cleft lip, cleft palate, or other craniofacial anomalies.
(3) Subject to the conditions and limitations of this section and other applicable WAC, the agency requires prior authorization for orthodontic treatment and/or orthodontic-related services for other dental malocclusions that are not listed in WAC 182-535A-0040(1).
[Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535A-0050, filed 3/25/14, effective 4/30/14. WSR 11-14-075, recodified as § 182-535A-0050, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 08-17-009, § 388-535A-0050, filed 8/7/08, effective 9/7/08. Statutory Authority: RCW 74.08.090, 74.09.520 and 74.09.035, 74.09.500. WSR 05-01-064, § 388-535A-0050, 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. 1396d(a), C.F.R. 440.100 and 225. WSR 02-01-050, § 388-535A-0050, filed 12/11/01, effective 1/11/02.]



182-535A-0060
Orthodontic treatment and orthodontic-related servicesPayment.

(1) The medicaid agency pays providers for furnishing covered orthodontic treatment and orthodontic-related services described in WAC 182-535A-0040 according to this section and other applicable WAC.
(2) A provider who furnishes covered orthodontic treatment and orthodontic-related services to an eligible client accepts the agency's fees as published in the agency's fee schedules according to WAC 182-502-0010.
(3) Providers must deliver services and procedures that are of acceptable quality to the agency. The agency may recoup payment for services determined to be below the standard of care or of an unacceptable product quality.
(4) Interceptive orthodontic treatment. The agency pays for interceptive orthodontic treatment on primary or transitional dentition in one payment that includes all professional fees, laboratory costs, and required follow-up.
(5) Limited orthodontic treatment. The agency pays for limited orthodontic treatment on transitional or adolescent dentition as follows:
(a) The first three months of treatment starts on the date the initial appliance is placed and includes active treatment for the first three months. The provider must bill the agency with the date of service that the initial appliance is placed.
(b) The agency's initial payment includes:
(i) The replacement of brackets and lost or broken orthodontic appliances;
(ii) Appliance removal;
(iii) The initial retainer fee; and
(iv) The final records (photos, a panoramic X-ray, a cephalometric film, and final trimmed study models).
(c) Continuing follow-up treatment must be billed as periodic orthodontic treatment visits.
(i) Payments are allowed once every six weeks during treatment, beginning three months after the initial appliance placement.
(ii) Payment for treatment provided in addition to the six periodic orthodontic treatment visits requires a limitation extension. See WAC 182-535A-0040(8).
(iii) If treatment is discontinued or treatment objectives are not achieved, providers must notify the agency. See WAC 182-535A-0040(7).
(6) Comprehensive full orthodontic treatment. The agency pays for comprehensive full orthodontic treatment on adolescent dentition as follows:
(a) The first three months of treatment starts the date the initial appliance is placed and includes active treatment for the first three months. The provider must bill the agency with the date of service that the initial appliance is placed.
(b) The agency's initial payment includes:
(i) The replacement of brackets and lost or broken orthodontic appliances;
(ii) Appliance removal;
(iii) The initial retainer fee; and
(iv) The final records (photos, a panoramic X-ray, a cephalometric film, and final trimmed study models).
(c) Continuing follow-up treatment must be billed as periodic orthodontic treatment visits.
(i) Payments are allowed once every six weeks during treatment, beginning three months after the initial appliance placement.
(ii) Payment for treatment provided in addition to the fourteen periodic orthodontic treatment visits requires a limitation extension. See WAC 182-535A-0040(8).
(iii) If treatment is discontinued or treatment objectives are not achieved, providers must notify the agency. See WAC 182-535A-0040(7).
(7) Case study. The agency pays for a case study, which includes:
(a) Preparation of comprehensive diagnostic records (additional photos, study casts, cephalometric examination film and panoramic film);
(b) Formation of diagnosis and treatment plan from such records; and
(c) Formal case conference.
(8) Payment for orthodontic treatment and orthodontic-related services is based on the agency's published fee schedule.
(9) Orthodontic providers who are in agency-designated bordering cities must:
(a) Meet the licensure requirements of their state; and
(b) Meet the same criteria for payment as in-state providers, including the requirements to contract with the agency.
(10) If the client's eligibility for orthodontic treatment under WAC 182-535A-0020 ends before the conclusion of the orthodontic treatment, payment for any remaining treatment is the client's responsibility. The agency does not pay for these services.
(11) The agency does not pay for orthodontic treatment provided after the client's twenty-first birthday. Payment for treatment that continues after the client's twenty-first birthday is the responsibility of the client.
(12) The client is responsible for payment of any orthodontic service or treatment received during any period of medicaid ineligibility, even if the treatment was started when the client was eligible.
(13) See WAC 182-502-0160 and 182-501-0200 for when a provider or a client is responsible to pay for a covered service.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-11-028, § 182-535A-0060, filed 5/7/19, effective 7/1/19; WSR 17-20-097, § 182-535A-0060, filed 10/3/17, effective 11/3/17; WSR 16-10-064, § 182-535A-0060, filed 5/2/16, effective 6/2/16. Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535A-0060, filed 3/25/14, effective 4/30/14. WSR 11-14-075, recodified as § 182-535A-0060, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 08-17-009, § 388-535A-0060, filed 8/7/08, effective 9/7/08. Statutory Authority: RCW 74.08.090, 74.09.520 and 74.09.035, 74.09.500. WSR 05-01-064, § 388-535A-0060, 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. 1396d(a), C.F.R. 440.100 and 225. WSR 02-01-050, § 388-535A-0060, filed 12/11/01, effective 1/11/02.]