Current through Register Vol. 24-18, September 15, 2024
Clients described in WAC
182-535-1060
are eligible to receive the dental-related diagnostic services listed in this
section, subject to coverage limitations, restrictions, and client age
requirements identified for a specific service.
(1)
Clinical oral evaluations.
The medicaid agency covers the following oral health evaluations and
assessments, per client, per provider or clinic:
(a) Periodic oral evaluations as defined in
WAC 182535-1050, once every six months. Six months must elapse between the
comprehensive oral evaluation and the first periodic oral evaluation.
(b) Limited oral evaluations as defined in
WAC 182535-1050, only when the provider performing the limited oral evaluation
is not providing routine scheduled dental services for the client on the same
day. The limited oral evaluation:
(i) Must be
to evaluate the client for a:
(A) Specific
dental problem or oral health complaint;
(B) Dental emergency; or
(C) Referral for other treatment.
(ii) When performed by a
denturist, is limited to the initial examination appointment. The agency does
not cover any additional limited examination by a denturist for the same client
until three months after a removable prosthesis has been delivered.
(c) Comprehensive oral evaluations
as defined in WAC
182-535-1050, once
per client, per provider or clinic, as an initial examination. The agency
covers an additional comprehensive oral evaluation if the client has not been
treated by the same provider or clinic within the past five years.
(d) Limited visual oral assessments as
defined in WAC
182-535-1050, two
times per client, per provider in a twelvemonth period only when the assessment
is:
(i) Not performed in conjunction with
other clinical oral evaluation services; and
(ii) Performed by a licensed dentist or
dental hygienist to determine the need for sealants or fluoride treatment or
when triage services are provided in settings other than dental offices or
clinics.
(2)
Radiographs (X-rays). The agency:
(a) Covers radiographs per client, per
provider or clinic, that are of diagnostic quality, dated, and labeled with the
client's name. The agency requires:
(i)
Original radiographs to be retained by the provider as part of the client's
dental record; and
(ii) Duplicate
radiographs to be submitted:
(A) With requests
for prior authorization; or
(B)
When the agency requests copies of dental records.
(b) Uses the prevailing standard
of care to determine the need for dental radiographs.
(c) Covers an intraoral complete series once
in a three-year period for clients age fourteen and older only if the agency
has not paid for a panoramic radiograph for the same client in the same
three-year period. The intraoral complete series typically includes fourteen to
twenty-two periapical and posterior bitewings. The agency limits reimbursement
for all radiographs to a total payment of no more than payment for a complete
series.
(d) Covers medically
necessary periapical radiographs for diagnosis in conjunction with definitive
treatment, such as root canal therapy. Documentation supporting medical
necessity must be included in the client's record.
(e) Covers an occlusal intraoral radiograph,
per arch, once in a two-year period, for clients age twenty and
younger.
(f) Covers a maximum of
four bitewing radiographs once every twelve months.
(g) Covers panoramic radiographs in
conjunction with four bitewings, once in a three-year period, only if the
agency has not paid for an intraoral complete series for the same client in the
same three-year period.
(h) Covers
one preoperative and postoperative panoramic radiograph per surgery without
prior authorization. The agency considers additional radiographs on a
case-by-case basis with prior authorization. For orthodontic services, see
chapter 182-535A WAC.
(i) Covers
one preoperative and postoperative cephalometric film per surgery without prior
authorization. The agency considers additional radiographs on a case-by-case
basis with prior authorization. For orthodontic services, see chapter 182-535A
WAC.
(j) Covers radiographs not
listed as covered in this subsection, only on a case-by-case basis and when
prior authorized.
(k) Covers oral
and facial photographic images, only on a case-by-case basis and when requested
by the agency.
(3)
Tests and examinations. The agency covers the following for
clients who are age twenty and younger:
One pulp vitality test per visit (not per tooth):
(a) For diagnosis only during limited oral
evaluations; and
(b) When
radiographs or documented symptoms justify the medical necessity for the pulp
vitality test.
Statutory Authority:
RCW
41.05.021. 12-09-081, §182-535-1080,
filed 4/17/12, effective 5/18/12. 11-14-075, recodified as §182-535-1080,
filed 6/30/11, effective 7/1/11. Statutory Authority:
RCW
74.08.090,
74.09.500,
74.09.520. 07-06-042, §
388-535-1080, 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. 03-19-078, § 388-535-1080, filed
9/12/03, effective 10/13/03. Statutory Authority:
RCW
74.08.090,
74.09.035,
74.09.500,
74.09.520,
42 U.S.C.
1396 d(a),
42 C.F.R.
440.100 and
440.225. 02-13-074, §
388-535-1080, filed 6/14/02, effective 7/15/02. Statutory Authority:
RCW
74.08.090,
74.09.035,
74.09.520 and
74.09.700,
42 USC
1396 d(a), C.F.R. 440.100 and 440.225.
99-07-023, § 388-535-1080, filed 3/10/99, effective
4/10/99.
