WAC 388-535-1280   Obtaining prior authorization for dental-related services for clients age twenty-one and older.  (1) The department uses the determination process described in WAC 388-501-0165 for covered dental-related services for clients age twenty-one and older that require prior authorization.

     (2) The department requires a dental provider who is requesting prior authorization to submit sufficient objective clinical information to establish medical necessity. The request must be submitted in writing on an American Dental Association (ADA) claim form, which may be obtained by writing to the American Dental Association, 211 East Chicago Avenue, Chicago, Illinois 60611.

     (3) The department may request additional information as follows:

     (a) Additional radiographs (X rays) (refer to WAC 388-535-1255(2));

     (b) Study models;

     (c) Photographs; and

     (d) Any other information as determined by the department.

     (4) The department may require second opinions and/or consultations before authorizing any procedure.

     (5) When the department authorizes a dental-related service for a client, that authorization indicates only that the specific service is medically necessary, it is not a guarantee of payment. The authorization is valid for six months and only if the client is eligible for covered services on the date of service.

     (6) The department denies a request for a dental-related service when the requested service:

     (a) Is covered by another department program;

     (b) Is covered by an agency or other entity outside the department; or

     (c) Fails to meet the program criteria, limitations, or restrictions in chapter 388-535 WAC.



[Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.520. 07-06-041, § 388-535-1280, filed 3/1/07, effective 4/1/07. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.530, 2003 1st sp.s. c 25, P.L. 104-191. 03-19-080, § 388-535-1280, filed 9/12/03, effective 10/13/03.]