DENTAL-RELATED SERVICES
Provider Guide
July 1, 2014
About this guide
*
This publication takes effect July 1, 2014, and supersedes earlier guides to this program.
Services, equipment, or both, related to any of the programs listed below must be billed using
their specific provider guides:
Access to Baby and Child Dentistry (ABCD)
Orthodontic Services
Washington Apple Health means the public health insurance programs for eligible
Washington residents. Washington Apple Health is the name used in Washington
State for Medicaid, the children's health insurance program (CHIP), and state-
only funded health care programs. Washington Apple Health is administered by
the Washington State Health Care Authority.
What has changed?
Subject
Change
Reason for Change
Nonsurgical periodontal
services
Added D4355 (full mouth debridement to enable
comprehensive evaluation and diagnosis) to the
fee schedule for DD clients only.
New billing code.
How can I get agency provider documents?
To download and print agency provider notices and provider guides, go to the agency’s Provider
Publications website.
Copyright disclosure
Current Dental Terminology © 2014, American Dental Association.
All rights reserved.
*
This publication is a billing instruction.
Dental-Related Services
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Table of Contents
Definitions .........................................................................................................................................1
About the Program ..........................................................................................................................5
What is the purpose of the Dental-Related Services program? ...................................................5
Who is eligible to become an agency-contracted provider? ........................................................5
Client Eligibility ...............................................................................................................................7
How can I verify a patient’s eligibility? ......................................................................................7
Are clients enrolled in managed care eligible? ............................................................................8
Coverage ...........................................................................................................................................9
When does the agency pay for covered dental-related services? .................................................9
What services performed in a hospital or ambulatory surgery center are covered? ....................9
Dental providers .....................................................................................................................9
Facilities .................................................................................................................................11
Site-of-service prior authorization .........................................................................................11
What services are covered under the EPSDT program? ..............................................................12
Which services are covered for medical care services (MCS) clients? .......................................12
Covered procedure codes for MCS clients ............................................................................13
Are limitation extensions (LE) and exceptions to rule (ETR) available? ....................................14
What is a limitation extension (LE)? .....................................................................................14
How do I request an LE? .......................................................................................................14
What is an exception to rule (ETR)?......................................................................................15
How do I request a noncovered service? ...............................................................................15
What diagnostic services are covered? ........................................................................................15
Oral health evaluations and assessments ...............................................................................15
Limited visual oral assessment ..............................................................................................16
Alcohol and substance misuse counseling .............................................................................17
X-rays (radiographs) ..............................................................................................................17
Tests and examinations ..........................................................................................................19
What preventive services are covered? ........................................................................................19
Dental prophylaxis .................................................................................................................19
Topical fluoride treatment......................................................................................................20
Oral hygiene instruction .........................................................................................................21
Tobacco cessation counseling ................................................................................................21
Sealants ..................................................................................................................................22
Space maintenance .................................................................................................................23
What restorative services are covered? ........................................................................................24
Amalgam and resin restorations for primary and permanent teeth ........................................24
Limitations for all restorations ...............................................................................................24
Additional limitations for restorations on primary teeth........................................................25
Dental-Related Services
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Additional limitations for restorations on permanent teeth ...................................................25
Crowns – single restorations only ..........................................................................................28
Other restorative services .......................................................................................................30
What endodontic services are covered? .......................................................................................33
Pulp capping...........................................................................................................................33
Pulpotomy/pulpal debridement ..............................................................................................33
Endodontic treatment on primary teeth..................................................................................34
Endodontic treatment on permanent teeth .............................................................................34
Endodontic retreatment on permanent teeth ..........................................................................35
Apexification/apicoectomy ....................................................................................................36
What periodontic services are covered? ......................................................................................37
Surgical periodontal services .................................................................................................37
Nonsurgical periodontal services ...........................................................................................37
Periodontal maintenance ........................................................................................................39
What prosthodontic (removable) services are covered? ..............................................................42
Complete dentures .................................................................................................................42
Resin Partial Dentures............................................................................................................43
Other requirements/limitations ..............................................................................................44
Adjustments to dentures .........................................................................................................44
Repairs to complete and partial dentures ...............................................................................44
Denture rebase procedures .....................................................................................................45
Denture reline procedures ......................................................................................................45
Other removable prosthetic services ......................................................................................46
Prior authorization for removable prosthodontic and prosthodontic-related
procedures ........................................................................................................................47
Alternative living facilities ....................................................................................................48
What maxillofacial prosthetic services are covered? ...................................................................48
What oral and maxillofacial surgery services are covered? .........................................................49
General coverage ...................................................................................................................49
Services exempt from site of service prior authorization ......................................................50
Documentation requirements .................................................................................................50
Extractions and surgical extractions ......................................................................................50
Other surgical procedures ......................................................................................................51
Alveoloplasty – surgical preparation of ridge for dentures ...................................................52
Surgical excision of soft tissue lesions ..................................................................................53
Excision of bone tissue ..........................................................................................................53
Surgical incision.....................................................................................................................54
Occlusal orthotic devices .......................................................................................................55
What orthodontic services are covered? ......................................................................................55
What adjunctive general services are covered? ...........................................................................56
Palliative treatment ................................................................................................................56
Anesthesia ..............................................................................................................................57
Professional visits and consultations .....................................................................................59
Drugs ......................................................................................................................................60
Behavior management ...........................................................................................................60
Postsurgical complications.....................................................................................................61
Dental-Related Services
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to go directly to the page. As an Adobe (.pdf) document, the guide also is easily navigated by using bookmarks
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document and select Navigation Pane Buttons. Click on the bookmark icon on the left of the document.)
Occlusal guards ......................................................................................................................61
What dental-related services are not covered? .............................................................................62
General – All ages ..................................................................................................................62
By category – For all ages .....................................................................................................62
By Category – For clients 21 years of age and older only .....................................................66
Clients of the Developmental Disabilities Administration ...........................................................68
Clients eligible for enhanced services..........................................................................................68
What additional dental-related services are covered for clients of the Developmental
Disabilities Administration? ..................................................................................................68
Preventive services.................................................................................................................68
Other restorative services .......................................................................................................69
Periodontic services ...............................................................................................................70
Adjunctive general services ...................................................................................................70
Nonemergency dental services ..............................................................................................71
Miscellaneous services-behavior management ......................................................................71
Authorization....................................................................................................................................72
General information about authorization .....................................................................................72
When do I need to get prior authorization (PA)? .........................................................................72
When does the agency deny a PA request? .................................................................................72
How do I obtain written PA? .......................................................................................................73
Removable dental prosthetics ................................................................................................73
Where do I send requests for PA?................................................................................................73
Without X-rays or photos.......................................................................................................74
With X-rays or photos ............................................................................................................74
What is expedited prior authorization (EPA)? .............................................................................75
EPA numbers .........................................................................................................................75
EPA procedure code list.........................................................................................................76
Billing ................................................................................................................................................77
What are the general billing requirements? .................................................................................77
How do facilities bill? ..................................................................................................................77
How do I bill for clients eligible for both Medicare and Medicaid? ...........................................78
How do I bill when there is third-party liability? ........................................................................78
What are the advance directives requirements? ...........................................................................78
Fee Schedule & ADA Claim Form ................................................................................................79
Where can I find dental fee schedules? ........................................................................................79
How do I complete the ADA claim form? ...................................................................................79
Dental-Related Services
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Definitions
This section defines terms and abbreviations, including acronyms, used in this provider guide. Please
refer to the agency’s online Washington Apple Health Glossary for a more complete list of definitions.
The agency also used dental definitions found in the current American Dental Association’s Current
Dental Terminology (CDT) and the current American Medical Association’s Physician’s Current
Procedural Terminology (CPT®). Where there is any discrepancy between this section and the
current CDT or CPT, this section prevails.
Adjunctive – A secondary treatment in
addition to the primary therapy.
Alternate Living Facility (ALF) – Refer to
WAC 182-513-1301.
Ambulatory Surgery Center (ASC) - Any
distinct entity certified by Medicare as an
ASC that operates exclusively for the
purpose of providing surgical services to
patients not requiring hospitalization.
American Dental Association (ADA) –
The ADA is a national organization for
dental professionals/dental societies.
(WAC 182-535-1050)
Anterior – The maxillary and mandibular
incisors and canines and tissue in the front
of the mouth.
Permanent maxillary anterior teeth
include teeth 6, 7, 8, 9, 10, and 11.
Permanent mandibular anterior teeth
include teeth 22, 23, 24, 25, 26, and 27.
Primary maxillary anterior teeth include
teeth C, D, E, F, G, and H.
Primary mandibular anterior teeth
include teeth M, N, O, P, Q, and R.
(WAC 182-535-1050)
Asymptomatic – Having or producing no
symptoms. (WAC 182-535-1050)
Base Metal – Dental alloy containing little
or no precious metals. (WAC 182-535-1050)
Behavior management – Using the
assistance of one additional dental
professional staff to manage the behavior of
a client to facilitate the delivery of dental
treatment. (WAC 182-535-1050)
Border Areas - See WAC 182-501-0175.
Caries – Carious lesions or tooth decay
through the enamel or decay of the root
surface. (WAC 182-535-1050)
Comprehensive oral evaluation – A
thorough evaluation and documentation of a
client’s dental and medical history to
include: extra-oral and intra-oral hard and
soft tissues, dental caries, missing or
unerupted teeth, restorations, occlusal
relationships, periodontal conditions
(including periodontal charting), hard and
soft tissue anomalies, and oral cancer
screening. (WAC 182-535-1050)
Conscious Sedation - A drug-induced
depression of consciousness during which a
client responds purposefully to verbal
commands, either alone or accompanied by
light tactile stimulation. No interventions
are required to maintain a patent airway,
Dental-Related Services
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spontaneous ventilation is adequate, and
cardiovascular function is maintained.
(WAC 182-535-1050)
Core build-up – Refers to building up of
clinical crowns, including pins.
(WAC 182-535-1050)
Coronal – The portion of a tooth that is
covered by enamel. (WAC 182-535-1050)
Coronal polishing – A mechanical
procedure limited to the removal of plaque
and stain from exposed tooth surfaces.
(WAC 182-535-1050)
Crown – A restoration covering or replacing
part or the whole clinical crown of a tooth.
(WAC 182-535-1050)
Current Dental Terminology (CDT™) - A
systematic listing of descriptive terms and
identifying codes for reporting dental
services and procedures performed by dental
practitioners. CDT is published by the
Council on Dental Benefit Programs of the
American Dental Association (ADA).
(WAC 182-535-1050)
Decay – A term for carious lesions in a
tooth and means decomposition of the tooth
structure. (WAC 182-535-1050)
Deep sedation – A drug-induced depression
of consciousness during which a client
cannot be easily aroused, ventilatory
function may be impaired, but the client
responds to repeated or painful stimulation.
(WAC 182-535-1050)
Dentures – An artificial replacement for
natural teeth and adjacent tissues, and includes
complete dentures, immediate dentures,
overdentures, and partial dentures.
(WAC 182-535-1050)
Denturist – A person licensed under Chapter
18.30 RCW to make, construct, alter,
reproduce, or repair a denture.
(WAC 182-535-1050)
Developmental Disabilities Administration
(DDA) – The administration within the
Department of Social and Health Services
responsible for administering and overseeing
services and programs for clients with
developmental disabilities. Formerly known
as the Division of Developmental Disabilities.
Endodontic – The etiology, diagnosis,
prevention, and treatment of diseases and
injuries of the pulp and associated
periradicular conditions.
(WAC 182-535-1050)
Extraction – See “simple extraction” and
“surgical extraction.”
Flowable composite – A diluted resin-based
composite dental restorative material that is
used in cervical restorations and small, low
stress bearing occlusal restorations.
Fluoride varnish, rinse, foam, or gel – A
substance containing dental fluoride, which is
applied to teeth.
General anesthesia – A drug-induced loss
of consciousness during which a client is not
arousable even by painful stimulation. The
ability to independently maintain ventilatory
function is often impaired. Clients may
require assistance in maintaining a patent
airway, and positive pressure ventilation
may be required because of depressed
spontaneous ventilation or drug-induced
depression of neuromuscular function.
Cardiovascular function may be impaired.
(WAC 182-535-1050)
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High noble metal – A dental alloy
containing at least 60% pure gold.
(WAC 182-535-1050)
Immediate denture - A prosthesis
constructed for placement immediately after
removal of remaining natural teeth on the
day of extractions.
Limited oral evaluation – An evaluation
limited to a specific oral health condition or
problem. Typically a client receiving this
type of evaluation has a dental emergency,
such as trauma or acute infection.
(WAC 182-535-1050)
Limited visual oral assessment – An
assessment by a dentist or dental hygienist
to determine the need for fluoride treatment
and/or when triage services are provided in
settings other than dental offices or dental
clinics. (WAC 182-535-1050)
Major bone grafts – A transplant of solid
bone tissue(s). (WAC 182-535-1050)
Minor bone grafts – A transplant of
nonsolid bone tissue(s), such as powdered
bone, buttons, or plugs.
(WAC 182-535-1050)
Noble metal – A dental alloy containing at
least 25% but less than 60% pure gold.
(WAC 182-535-1050)
Oral hygiene instruction – Instruction for
home oral hygiene care, such as tooth
brushing techniques or flossing.
(WAC 182-535-1050)
Oral prophylaxis – The dental procedure of
scaling and polishing that includes removal
of calculus, plaque, and stains from teeth.
(WAC 182-535-1050)
Partials or partial dentures – A removable
prosthetic appliance that replaces missing
teeth in one arch.
(WAC 182-535-1050)
Periodic oral evaluation – An evaluation
performed on a patient of record to
determine any changes in the client’s dental
or medical status since a previous
comprehensive or periodic evaluation.
(WAC 182-535-1050)
Periodontal maintenance – A procedure
performed for clients who have previously
been treated for periodontal disease with
surgical or nonsurgical treatment. It
includes the removal of supragingival and
subgingival micro-organisms and deposits
with hand and mechanical instrumentation,
an evaluation of periodontal conditions, and
a complete periodontal charting as
appropriate. (WAC 182-535-1050)
Periodontal scaling and root planing – A
procedure to remove plaque, calculus,
micro-organisms, and rough cementum and
dentin from tooth surfaces. This includes
hand and mechanical instrumentation, an
evaluation of periodontal conditions, and a
complete periodontal charting as
appropriate. (WAC 182-535-1050)
Permanent – The permanent or adult teeth
in the dental arch.
Posterior – The teeth (maxillary and
mandibular premolars and molars) and
tissue towards the back of the mouth.
Permanent maxillary posterior teeth
include teeth 1, 2, 3, 4, 5, 12, 13, 14, 15,
and 16.
Permanent mandibular posterior teeth
include teeth 17, 18, 19, 20, 21, 28, 29,
30, 31, and 32.
Dental-Related Services
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Primary maxillary posterior teeth include
teeth A, B, I, and J.
Primary mandibular posterior teeth
include teeth K, L, S, and T.
(WAC 182-535-1050)
Primary – The first set of teeth.
Proximal – The surface of the tooth near or
next to the adjacent tooth.
Radiograph (X-ray) – An image or picture
produced on a radiation sensitive film
emulsion or digital sensor by exposure to
ionizing radiation.
(WAC 182-535-1050)
Reline – To resurface the tissue side of a
denture with new base material or soft tissue
conditioner in order to achieve a more
accurate fit. (WAC 182-535-1050)
Root canal - The chamber within the root of
the tooth that contains the pulp.
(WAC 182-535-1050)
Root canal therapy - The treatment of the
pulp and associated periradicular conditions.
Root planing – A procedure to remove
plaque, calculus, micro-organisms, rough
cementum, and dentin from tooth surfaces.
This includes use of hand and mechanical
instrumentation. (WAC 182-535-1050)
Scaling – A procedure to remove plaque,
calculus, and stain deposits from tooth
surfaces. (WAC 182-535-1050)
Sealant – A dental material applied to teeth
to prevent dental caries.
(WAC 182-535-1050)
Simple extraction – The routine removal of
a tooth. (WAC 182-535-1050)
Standard of care – What reasonable and
prudent practitioners would do in the same
or similar circumstances.
(WAC 182-535-1050)
Supernumerary teeth – Extra erupted or
unerupted teeth that resemble teeth of
normal shape designated by the number
series 51 through 82 and AS through TS.
Surgical extraction – The removal of a
tooth by cutting of the gingiva and bone.
This includes soft tissue extractions, partial
boney extractions, and complete boney
extractions. (WAC 182-535-1050)
Symptomatic – Having symptoms (e.g.,
pain, swelling, and infection).
(WAC 182-535-1050)
Temporomandibular joint dysfunction
(TMJ/TMD) – An abnormal functioning of
the temporomandibular joint or other areas
secondary to the dysfunction.
(WAC 182-535-1050)
Therapeutic pulpotomy – The surgical
removal of a portion of the pulp (inner soft
tissue of a tooth), to retain the healthy
remaining pulp. (WAC 182-535-1050)
Wisdom teeth – The third molars, teeth 1,
16, 17, and 32. (WAC 182-535-1050)
Xerostomia – A dryness of the mouth due
to decreased saliva. (WAC 182-535-1050)
Dental-Related Services
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About the Program
What is the purpose of the Dental-Related
Services program?
The purpose of the Dental-Related Services program is to provide quality dental and dental-
related services to eligible Washington Apple Health clients, subject to the limitations,
restrictions, and age requirements identified in this billing guide.
Who is eligible to become an agency-contracted
provider?
(WAC 182-535-1070)
The following providers are eligible to enroll with the agency to furnish and bill for dental-
related services provided to eligible clients:
Persons currently licensed by the state of Washington to:
Practice dentistry or specialties of dentistry
Practice medicine and osteopathy for either of the following:
Oral surgery procedures.
Providing fluoride varnish under EPSDT.
Practice as a dental hygienist
Practice as a denturist
Practice anesthesia according to Department of Health (DOH) regulations
Facilities that are one of the following:
Hospitals currently licensed by the Department of Health (DOH)
Federally-qualified health centers (FQHCs)
Medicare-certified ambulatory surgery centers (ASCs)
Medicare-certified rural health clinics (RHCs)
Community health centers (CHC)
Participating local health jurisdictions
Dental-Related Services
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Border area providers of dental-related services who are qualified in their states to
provide these services
Note: The agency pays licensed providers participating in the agency’s Dental-
Related Services Program for only those services that are within their scope of
practice. (WAC 182-535-1070(2))
Dental-Related Services
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Client Eligibility
How can I verify a patient’s eligibility?
Providers must verify that a patient has Washington Apple Health coverage for the date of
service, and that the client’s benefit package covers the applicable service. This helps prevent
delivering a service the agency will not pay for.
Verifying eligibility is a two-step process:
Step 1. Verify the patient’s eligibility for Washington Apple Health. For detailed
instructions on verifying a patient’s eligibility for Washington Apple Health, see the
Client Eligibility, Benefit Packages, and Coverage Limits section in the agency’s
current ProviderOne Billing and Resource Guide.
If the patient is eligible for Washington Apple Health, proceed to Step 2. If the patient
is not eligible, see the note box below.
Step 2. Verify service coverage under the Washington Apple Health client’s benefit
package. To determine if the requested service is a covered benefit under the
Washington Apple Health client’s benefit package, see the agency’s Health Care
Coverage—Program Benefit Packages and Scope of Service Categories web page.
Note: Patients who are not Washington Apple Health clients may submit an
application for health care coverage in one of the following ways:
1. By visiting the Washington Healthplanfinder’s website at:
www.wahealthplanfinder.org.
2. By calling the Customer Support Center toll-free at: 855-WAFINDER
(855-923-4633) or 855-627-9604 (TTY).
3. By mailing the application to:
Washington Healthplanfinder
PO Box 946
Olympia, WA 98507
In-person application assistance is also available. To get information about in-
person application assistance available in their area, people may visit
www.wahealthplanfinder.org or call the Customer Support Center.
Dental-Related Services
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Are clients enrolled in managed care eligible?
(WAC 182-535-1060(1)(b)(ii))
Yes. Dental-related services, including surgical services with a dental-related diagnosis, for
eligible clients enrolled in an agency-contracted managed care organization (MCO) are covered
under Washington Apple Health fee-for-service. Bill the agency directly for all dental-related
services provided to eligible agency-contracted MCO clients.
Dental-Related Services
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Coverage
When does the agency pay for covered dental-
related services?
(WAC 182-535-1079 (1))
Subject to coverage limitations and client-age requirements identified for a specific service, the
agency pays for dental-related services and procedures when the services are all of the following:
Part of the client’s benefit package
Within the scope of an eligible client's Washington Apple Health program
Medically necessary
Meet the agency’s prior authorization requirements, if any
Documented in the client’s record
Within accepted dental or medical practice standards
Consistent with a diagnosis of dental disease or condition
Reasonable in amount and duration of care, treatment, or service
Listed as covered in this provider guide
For orthodontic services, see Chapter 182-535A WAC and the agency’s Orthodontic Services
Provider Guide.
What services performed in a hospital or
ambulatory surgery center are covered?
Dental providers
The agency covers evaluation and management (E/M) codes (formerly hospital visits and
consults) when an oral surgeon is called to the hospital or is sent a client from the
hospital for an emergency condition (i.e., infection, fracture, or trauma).
When billing for E/M codes in facility settings, oral surgeons must use CPT codes and
follow CPT rules, including the use of modifiers. When billing for emergency hospital
visits, oral surgeons must bill:
On an 837P HIPAA compliant claim form, Professional claim billed via Direct
Data Entry (DDE), or CMS-1500 paper claim form.
Using the appropriate CPT code and modifiers, if appropriate.
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The agency requires prior authorization (PA) for CDT dental services performed in a
hospital or an ASC for clients 9 years of age and older (except for clients of the
Developmental Disabilities Administration)
The place-of-service (POS) on the submitted claim form must match the setting where
the service is performed. The agency may audit claims with an incorrect POS and
payment may be recouped.
Place of Service
Setting
21
Inpatient hospital
22
Outpatient hospital
24
Ambulatory surgery center
The dentist providing the service must send in a request for authorization to perform the
procedure in this setting. The request must:
Contain all procedure codes, including procedure codes that require PA according
to this provider guide.
Note: Authorization for a client to be seen in a hospital or ASC setting
does not automatically authorize any specific code that requires PA. If the
specific code requires PA, also include the rationale for the code.
Be submitted on the General Information for Authorization form, HCA 13-835.
Include a letter that clearly describes the medical necessity of performing the
service in the requested setting.
Note: Any PA request submitted without the above information will be returned
as incomplete.
The agency requires providers to report dental services, including oral and maxillofacial
surgeries, using CDT codes.
Exception: Oral surgeons may use CPT codes listed in the agency’s
Physician-Related/Professional Services Fee Schedule only when the
procedure performed is not listed as a covered CDT code in the agency’s
Dental Program Fee Schedule. CPT codes must be billed on an
837P/CMS-1500 claim form.
The agency pays dentists and oral surgeons for hospital visits using only the CPT codes
listed in the oral surgery section of the Physician-Related Services/Health Care
Professional Services Provider Guide. In accordance with CPT guidelines, evaluation
and management codes (visit codes) are not allowed on the same day as a surgery code
(CPT or CDT) unless the decision to do the surgery was made that day and appropriate
modifiers are used.
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If requesting anesthesia time that is significantly greater than the normal anesthesia time
for the procedure, include the medical justification for this in the documentation.
Facilities
Hospitals and ambulatory surgery centers (ASCs) must use CDT codes for dental
procedures. Hospitals and ASCs may bill with a CPT code only if there is no CDT code
that covers the service performed.
Coverage and payment is limited to those CDT and select CPT codes listed in the
agency’s Dental Program Fee Schedule.
ASCs are paid only for the codes listed in the agency’s Ambulatory Surgery Centers
Provider Guide.
The agency considers anesthesia to be included in the payment made to the facility. The
agency does not pay separately, even if a facility bills CDT code D9220/D9221 or
D9241/D9242.
Hospitals and ASCs may use CPT code 41899 only when there is no existing national
code that describes the services being provided. The agency considers this code for
payment only when the performing dentist submits a PA request with justification
explaining that there is no existing national code describing the services being provided.
Site-of-service prior authorization
(WAC 182-535-1079 (3), (4))
The agency requires site-of-service prior authorization, in addition to prior authorization of the
procedure, if applicable, for nonemergency dental-related services performed in a hospital or an
ambulatory surgery center (ASC) when all of the following are true:
The client is not a client of the Developmental Disabilities Administration.
The client is 9 years of age or older.
The service is not listed as exempt from the site-of-service authorization requirement in
this provider guide or the agency’s current published Dental-Related Services Fee
Schedule.
The service is not listed as exempt from the prior authorization requirement for deep
sedation or general anesthesia (see What adjunctive general services are covered?).
Dental-Related Services
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To be eligible for payment, dental-related services performed in a hospital or an ASC must be
listed in the agency’s current published Outpatient Fee Schedule or ASC Fee Schedule. The
claim must be billed with the correct procedure code for the site-of-service.
What services are covered under the EPSDT
program?
(WAC 182-535-1079 (5))
Under the Early Periodic Screening and Diagnostic Treatment (EPSDT) program, clients 20
years of age and younger may be eligible for the dental-related services listed as noncovered.
The agency reviews requests for dental-related services for clients who are eligible for services
under the EPSDT program when a referral for services is the result of an EPSDT exam,
according to the provisions of WAC 182-534-0100.
Which services are covered for medical care
services (MCS) clients?
(WAC 182-535-1066)
The agency covers the following dental-related services for a medical care services (MCS) client
as listed in WAC 182-501-0060 when the services are provided by a dentist to assess and treat
pain, infection, or trauma of the mouth, jaw, or teeth, including treatment of post-surgical
complications, (e.g., dry socket):
Limited oral evaluation
Periapical or bite-wing radiographs (X-rays) that are medically necessary to diagnose
only the client’s chief complaint
Palliative treatment to relieve dental pain
Pulpal debridement to relieve dental pain
Tooth extraction. Tooth extractions require prior authorization (PA) when one of the
following applies:
The extraction of a tooth or teeth results in the client becoming edentulous in the
maxillary arch or mandibular arch.
A full mouth extraction is necessary because of radiation therapy for cancer of the
head and neck.
Dental-Related Services
- 13 -
Each dental-related procedure described under this section is subject to the coverage
limitations listed in this provider guide.
The agency does not cover any dental-related services not listed in this section for MCS
clients, including any type of removable dental prosthesis.
Covered procedure codes for MCS clients
Code
Description
PA?
Requirements/
Limitations
Maximum
Allowable
Fee
D0140
limited oral evaluation – problem
focused
N
On-line Fee
Schedule
D0220
intraoral – periapical first film
N
D0230
intraoral – periapical each
additional film
N
D0270
bitewing – single film
N
D0272
bitewings – two films
N
D0273
bitewings – three films
N
D0274
bitewings – four films
N
D3221
pulpal debridement, primary and
permanent teeth
N
Tooth designation
required
D3310
anterior (excluding final
restoration)
N
Tooth designation
required
D7111
extraction, coronal remnants –
deciduous tooth
N
Tooth designation
required
D7140
extraction, erupted tooth or
exposed root (elevation and/or
forceps removal)
N
Tooth designation
required
D7210
surgical removal of erupted tooth
requiring removal of bone and/or
sectioning of tooth, and including
elevation of mucoperiosteal flap
if indicated
N
Tooth designation
required
D7220
removal of impacted tooth – soft
tissue
N
Tooth designation
required
D7230
removal of impacted tooth –
partially bony
N
Tooth designation
required
D7240
removal of impacted tooth –
completely bony
N
Tooth designation
required
D7250
surgical removal of residual tooth
roots (cutting procedure)
*
Tooth designation
required
D9110
palliative (emergency) treatment
of dental pain – minor procedure
N
Tooth designation
required.
*This service must be prior authorized by the agency if provided by the original treating provider or
clinic.
Dental-Related Services
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Are limitation extensions (LE) and exceptions to
rule (ETR) available?
(WAC 182-535-1079 (5))
What is a limitation extension (LE)?
A limitation extension (LE) is an authorization of services beyond the designated benefit limit
allowed in Washington Administration Code (WAC) and agency Washington Apple Health
provider guides.
Note: A request for a limitation extension must be appropriate to the client’s
eligibility and/or program limitations. Not all eligibility groups cover all services.
The agency evaluates a request for dental-related services that are in excess of the Dental
Program’s limitations or restrictions, according to WAC 182-501-0169.
How do I request an LE?
The agency requires a dental provider who is requesting an LE to submit sufficient, objective,
clinical information to establish medical necessity.
Providers must submit the request in writing on a completed General Information
for Authorization form, HCA 13-835. See the agency’s current ProviderOne Billing and
Resource Guide for more information.
The agency may request additional information as follows:
Additional X-rays (radiographs) (the agency returns X-rays only for approved
requests and only if accompanied by self-addressed stamped envelope)
Study model, if requested
Photographs
Any other information requested by the agency
Note: The agency may require second opinions and/or consultations before
authorizing any procedure.
Removable Dental Prosthetics
For nursing facility clients, the LE request must also include a completed copy of the
Denture/Partial Appliance Request for Skilled Nursing Facility Client form, HCA 13-
788.
Dental-Related Services
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What is an exception to rule (ETR)?
An ETR is when a client or the client’s provider requests the agency to pay for a
noncovered service. The agency reviews these requests according to WAC 182-501-0160.
How do I request a noncovered service?
A noncovered service must be requested through ETR. To request a noncovered service,
submit the request in writing on a completed General Information for Authorization form,
HCA 13-835, and fax to the agency at: (866) 668-1214.
Indicate in Box 30 on the form that you are requesting an ETR.
Be sure to provide all of the evidence required by WAC 182-501-0160.
What diagnostic services are covered?
(WAC 182-535-1080)
Subject to coverage limitations, restrictions, and client-age requirements identified for a specific
service, the agency covers the following dental-related diagnostic services:
Oral health evaluations and assessments
The agency covers per client, per provider or clinic:
Periodic oral evaluations, once every six months. Six months must elapse between the
comprehensive oral evaluation and the first periodic oral evaluation. Exception to
limits, see Clients of the Developmental Disabilities Administration, Preventive Services.
Limited oral evaluations, 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:
Must be to evaluate the client for one of the following:
Specific dental problem or oral health complaint
Dental emergency
Referral for other treatment
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 dental prosthesis has been
delivered.
Dental-Related Services
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Comprehensive oral evaluations, once per client, per provider or clinic, as an initial
examination that must include:
A complete dental and medical history and general health assessment.
A complete thorough evaluation of extra-oral and intra-oral hard and soft tissue.
The evaluation and recording of dental caries, missing or unerupted teeth,
restoration, occlusal relationships, periodontal conditions (including periodontal
charting), hard and soft tissue anomalies, and oral cancer screening.
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 or for established patients
who have a documented significant change in health conditions (see EPA).
Note: The agency does not pay separately for chart or record set-up. The fees
for these services are included in the agency’s reimbursement for comprehensive
oral evaluations.
CDT
Code
Description
PA?
Maximum
Allowable Fee
D0120
periodic oral evaluation – established patient*
N
On-line Fee
Schedule
D0140
limited oral evaluation – problem focused*
N
D0150
comprehensive oral evaluation – new or
established patient*
N
*Oral surgeons may bill E/M codes (CPT 99201-99215) on an 837P/CMS-1500 claim to
represent these services instead of CDT codes.
Limited visual oral assessment
The agency covers limited visual oral assessments or screening, up to two per client, per year,
per provider only when the assessment or screening is:
Not performed in conjunction with other clinical oral evaluation services.
Performed by a licensed dentist or dental hygienist to determine the need for sealants,
fluoride treatment, and/or when triage services are provided in settings other than
dental offices or dental clinics (e.g., alternative living facilities, etc.).
Provided by a licensed dentist or licensed dental hygienist.
Only one screening or assessment covered per client per visit.
Dental-Related Services
- 17 -
CDT
Code
Description
PA?
Maximum
Allowable Fee
D0190
screening of a patient
N
On-line Fee
Schedule
D0191
assessment of a patient
N
Alcohol and substance misuse counseling
The agency covers alcohol and substance misuse counseling through screening, brief
interventions, and referral to treatment (SBIRT) services when provided by, or under the
supervision of, a certified physician or other certified licensed health care professional, such as a
dentist or a dental hygienist, within the scope of their practice. See the agency’s current
Physician-Related Services/Health Care Professional Services Provider Guide.
X-rays (radiographs)
The agency uses the prevailing standard of care to determine the need for dental X-rays
(radiographs).
The agency covers:
X-rays, per client, per provider or clinic, that are of diagnostic quality, dated, and labeled
with the client's name. The agency requires:
Original X-rays to be retained by the provider as part of the client's dental record.
Duplicate X-rays to be submitted with requests for prior authorization and when
the agency requests copies of dental records.
An intraoral complete series, once in a three-year period for clients 14 years of age and
older only if the agency has not paid for a panoramic X-ray for the same client in the
same three-year period. The intraoral complete series includes at least 14 to 22 periapical
and posterior bitewings. The agency limits reimbursement for all X-rays to a total
payment of no more than the payment for a complete series.
Medically necessary periapical X-rays that are not included in a complete series for
diagnosis in conjunction with definitive treatment, such as root canal therapy.
Documentation supporting medical necessity must be included in the client's record.
An occlusal intraoral X-ray once in a two-year period, for clients 20 years of age and
younger.
A maximum of four bitewing X-rays once every twelve months.
Dental-Related Services
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Panoramic X-rays (for dental only) 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.
Preoperative and postoperative panoramic X-ray, one per surgery without prior
authorization. The agency considers additional X-rays on a case-by-case basis with prior
authorization. For orthodontic services, see the Orthodontic Services Provider Guide.
Cephalometric films - One preoperative and postoperative cephalometric film per surgery
without prior authorization. Additional X-rays will be considered on a case-by-case basis
with prior authorization.
X-rays not listed as covered, only on a case-by-case basis and when prior authorized.
CDT
Code
Description
PA?
Age Limitation
Maximum
Allowable Fee
D0210
intraoral – complete series
(including bitewings)
N
On-line Fee
Schedule
D0220
intraoral – periapical first film
N
D0230
intraoral – periapical each
additional film
N
D0240
intraoral – occlusal film
N
Clients 20 years of age
and younger only.
D0270
bitewing – single film
N
D0272
bitewings – two films
N
D0273
bitewings – three films
N
D0274
bitewings – four films
N
D0330
panoramic film
N
D0340
cephalometric film (oral surgeons
only)
N
Oral and facial photographic images on a case-by-case basis and when requested by the
agency.
CDT
Code
Description
PA?
Age Limitation
Maximum
Allowable Fee
D0350
oral/facial photographic images
obtained intraorally or extraorally
Y
Clients 20 years of
age and younger
only.
On-line Fee
Schedule
Note: The agency does not require PA for additional medically necessary
panoramic X-rays ordered by oral surgeons and orthodontists.
Dental-Related Services
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Tests and examinations
The agency covers the following:
One pulp vitality test per visit (not per tooth):
For diagnosis only during limited oral evaluations
When X-rays and/or documented symptoms justify the medical necessity for the
pulp vitality test
CDT
Code
Description
PA?
Maximum Allowable Fee
D0460
pulp vitality tests
N
On-line Fee Schedule
Diagnostic casts other than those included in an orthodontic case study, on a case-by-case
basis, and when requested by the agency.
CDT
Code
Description
PA?
Maximum Allowable Fee
D0470
diagnostic casts
Y
On-line Fee Schedule
Note: The agency covers viral cultures, genetic testing, caries susceptibility, and
adjunctive pre-diagnostic tests only on a case-by-case basis and when requested
by the agency.
What preventive services are covered?
(WAC 182-535-1082)
Dental prophylaxis
The agency:
Includes scaling and polishing procedures to remove coronal plaque, calculus, and stains
when performed on a primary or permanent dentition as part of the prophylaxis service.
Limits prophylaxis once every:
6 months for a client 18 years of age and younger.
12 months for a client 19 years of age and older.
4 months for a client residing in a nursing facility.
Dental-Related Services
- 20 -
Exception: Clients of the Developmental Disabilities Administration may exceed these
limits.
Reimburses only when the prophylaxis is performed:
At least 6 months after periodontal scaling and root planing, or periodontal
maintenance services, for clients from 13 to 18 years of age.
At least 12 months after periodontal scaling and root planing, or periodontal
maintenance services, for clients from 19 years of age and older.
At least 6 months after periodontal scaling and root planing, or periodontal
maintenance services for clients who reside in a nursing facility.
Does not reimburse for prophylaxis separately when it is performed on the same date of
service as periodontal scaling and root planing, periodontal maintenance, gingivectomy,
or gingivoplasty.
Covers prophylaxis for clients of the Developmental Disabilities Administration.
CDT
Code
Description
PA?
Age Limitation
Maximum
Allowable Fee
D1110
prophylaxis – adult
N
Clients 14 years of
age and older only
On-line Fee
Schedule
D1120
prophylaxis – child
N
Clients through
age 13 only
Topical fluoride treatment
The agency covers fluoride rinse, foam or gel, or fluoride varnish, including disposable trays, per
client, per provider or clinic as follows:
Clients who are…
Frequency
6 years of age and younger OR
Receiving orthodontic treatment OR
Residing in alternate living facilities
Up to 3 times within a 12-month period
7 through 18 years of age
Up to 2 time within a 12-month period
19 years of age and older
Once within a 12-month period
Additional topical fluoride applications only on a case-by-case basis and when prior
authorized
Dental-Related Services
- 21 -
Topical fluoride treatment for clients of the Developmental Disabilities Administration
CDT
Code
Description
PA?
Maximum Allowable Fee
D1206*
topical fluoride
varnish.
N
On-line Fee Schedule
D1208*
topical application of
fluoride
N
* CDT codes D1206 and D1208 are not allowed on the same day. The fluoride limit per
provider, per client, for CDT codes D1206 and D1208 is the combined total of the two; not
per code. The codes are considered equivalent, and a total of 3 or 2 fluorides are allowed,
not 3 or 2 of each.
Oral hygiene instruction
The agency covers oral hygiene instruction only for clients who are 8 years of age and younger.
Oral hygiene instruction includes individualized instruction for home care such as tooth brushing
techniques, flossing, and use of oral hygiene aids.
The agency covers oral hygiene instruction as follows:
Once every 6 months (up to 2 times within a 12-month period)
Only when not performed on the same date of service as prophylaxis
Note: The agency covers oral hygiene instruction only when provided by a
licensed dentist or a licensed dental hygienist and the instruction is provided in a
setting other than a dental office or clinic.
CDT
Code
Description
PA?
Age
Limitation
Maximum
Allowable Fee
D1330
oral hygiene instructions
N
*Clients 8 years
of age and
younger only
On-line Fee
Schedule
*For clients nine years of age and older, oral hygiene instruction is included as part of the global fee for
oral prophylaxis.
Tobacco cessation counseling
The agency covers tobacco cessation counseling for clients 18 years of age and older and
pregnant women any age for the control and prevention of oral disease. Refer to the Physician
Related Services/Health Care Professional Services Provider Guide.
Dental-Related Services
- 22 -
Sealants
The agency covers sealants as follows:
For clients 20 years of age and younger and clients any age of the Developmental
Disabilities Administration (DDA), Department of Social and Health Services (DSHS)
Only when used on a mechanically and/or chemically prepared enamel surface.
Once per tooth:
In a 3-year period for clients 20 years of age and younger
In a two-year period for clients of any age of the Developmental Disabilities
Administration (DDA), DSHS
Additional sealants are allowed on a case-by-case basis and when prior authorized
Only when used on the occlusal surfaces of:
Permanent teeth 2, 3, 14, 15, 18, 19, 30, and 31
Primary teeth A, B, I, J, K, L, S, and T
On noncarious teeth or teeth with incipient caries
Only when placed on a tooth with no pre-existing occlusal restoration, or any occlusal
restoration placed on the same day
Sealants are included in the agency’s payment for occlusal restoration placed on the same day
CDT
Code
Description
PA?
Requirements
Age Limitation
Maximum
Allowable Fee
D1351
sealant – per tooth
N
Tooth and
surface
designation
required
Clients 20 years
of age and
younger; clients
any age of
DDA/DSHS
On-line Fee
Schedule
Dental-Related Services
- 23 -
Space maintenance
The agency covers:
Fixed unilateral or fixed bilateral space maintainers, including recementation, for missing
primary molars A, B, I, J, K, L, S, and T, subject to the following:
Only when there is evidence of pending permanent tooth eruption
Only one space maintainer is covered per quadrant
Replacement space maintainers are covered only on a case-by-case basis and
when prior authorized
The removal of fixed space maintainers when removed by a different provider. Allowed
once per quadrant
CDT
Code
Description
PA?
Requirements
Maximum
Allowable Fee
D1510
space maintainer –
fixed – unilateral
N
Quadrant designation
required
On-line Fee
Schedule
D1515
space maintainer –
fixed – bilateral
N
Arch designation required
D1550
re-cementation of
space maintainer
N
Quadrant or arch
designation required
On-line Fee
Schedule
D1555
removal of fixed
space maintainer
N
Dental-Related Services
- 24 -
What restorative services are covered?
(WAC 182-535-1084)
Amalgam and resin restorations for primary and permanent
teeth
The agency considers:
Tooth preparation, acid etching, all adhesives (including bonding agents), liners and
bases, polishing, and curing as part of the restoration.
Occlusal adjustment of either the restored tooth or the opposing tooth or teeth as part of
the amalgam restoration.
Restorations placed within six months of a crown preparation by the same provider or
clinic to be included in the payment for the crown.
Limitations for all restorations
The agency:
Considers multiple restorations involving the proximal and occlusal surfaces of the same
tooth as a multisurface restoration, and limits reimbursement to a single multisurface
restoration.
Considers multiple preventive restorative resins, flowable composite resins, or resin-
based composites for the occlusal, buccal, lingual, mesial, and distal fissures and grooves
on the same tooth as a one-surface restoration.
Considers multiple restorations of fissures and grooves of the occlusal surface of the
same tooth as a one-surface restoration.
Considers resin-based composite restorations of teeth where the decay does not penetrate
the dentoenamel junction (DEJ) to be sealants. (See What preventive services are
covered?)
Reimburses proximal restorations that do not involve the incisal angle on anterior teeth as
a two-surface restoration.
Covers only one buccal and one lingual surface per tooth. The agency reimburses buccal
or lingual restorations, regardless of size or extension, as a one-surface restoration.
Dental-Related Services
- 25 -
Does not cover preventive restorative resin or flowable composite resin on the
interproximal surfaces (mesial or distal) when performed on posterior teeth or the incisal
surface of anterior teeth.
Does not pay for replacement restorations within a two-year period unless the restoration
has an additional adjoining carious surface. The agency pays for the replacement
restoration as one multisurface restoration per client, per provider or clinic. The client's
record must include X-rays and documentation supporting the medical necessity for the
replacement restoration.
Additional limitations for restorations on primary teeth
The agency covers:
A maximum of two surfaces for a primary first molar. (See Other restorative services for
a primary first molar that requires a restoration with three or more surfaces.) The agency
does not pay for additional restorations on the same tooth.
A maximum of three surfaces for a primary second molar. (See Other restorative
services for a primary posterior tooth that requires a restoration with four or more
surfaces.) The agency does not pay for additional restorations on the same tooth.
A maximum of three surfaces for a primary anterior tooth. (See Other restorative
services for a primary anterior tooth that requires a restoration with four or more
surfaces.) The agency does not pay for additional restorations on the same tooth after
three surfaces.
Glass ionomer restorations for primary teeth, only for clients 5 years of age and younger.
The agency pays for these restorations as a one-surface, resin-based composite
restoration.
Additional limitations for restorations on permanent teeth
The agency covers:
Two occlusal restorations for the upper molars on teeth 1, 2, 3, 14, 15, and 16, only if the
restorations are anatomically separated by sound tooth structure.
A maximum of five surfaces per tooth for permanent posterior teeth, except for upper
molars. The agency allows a maximum of six surfaces per tooth for teeth 1, 2, 3, 14, 15,
and 16.
Dental-Related Services
- 26 -
A maximum of six surfaces per tooth for resin-based composite restorations for
permanent anterior teeth.
CDT
Code
Description
PA?
Requirements
Maximum
Allowable Fee
D2140
amalgam – one surface, primary
or permanent
N
Tooth and surface
designations
required
On-line Fee
Schedule
D2150
amalgam – two surfaces,
primary or permanent
N
Tooth and surface
designations
required
D2160
amalgam – three surfaces,
primary or permanent
N
Tooth and surface
designations
required. If billed on
a primary first molar,
the agency will
reimburse at the rate
for a two-surface
restoration.
D2161
amalgam – four or more
surfaces, primary or permanent
N
Tooth and surface
designations
required. If billed on
a primary first molar,
the agency will
reimburse at the rate
for a two-surface
restoration. If billed
on a primary second
molar, the agency
will reimburse at the
rate for a three-
surface restoration.
D2330
resin-based composite – one
surface, anterior
N
Tooth and surface
designations required
D2331
resin-based composite – two
surfaces, anterior
N
Tooth and surface
designations required
D2332
resin-based composite – three
surfaces, anterior
N
Tooth and surface
designations required
D2335
resin-based composite – four or
more surfaces or involving
incisal angle (anterior)
N
Tooth and surface
designations
required. Not
allowed on primary
teeth.
Dental-Related Services
- 27 -
CDT
Code
Description
PA?
Requirements
Maximum
Allowable Fee
D2390
resin-based composite crown,
anterior
N*
Tooth designation
required.
Clients 20 years of
age and younger
only.
On-line Fee
Schedule
D2391
resin-based composite – one
surface, posterior
N
Tooth and surface
designations required
* For primary anterior teeth, once every three years as follows: Clients 12 years of age and
younger without PA if the tooth requires a four or more surface restoration. Clients 13 through
20 years of age with PA. X-ray justification is required.
CDT
Code
Description
PA?
Requirements
Maximum
Allowable Fee
D2392
resin-based composite – two
surfaces, posterior
N
Tooth and surface
designations required
On-line Fee
Schedule
D2393
resin-based composite – three
surfaces, posterior
N
Tooth and surface
designations
required. If billed on
a primary first molar,
the agency will
reimburse at the rate
for a two-surface
restoration. If billed
on a primary second
molar, the agency
will reimburse at the
rate for a three-
surface restoration.
D2394
resin-based composite – four or
more surfaces, posterior
N
Tooth and surface
designations
required. If billed on
a primary first molar,
the agency will
reimburse at the rate
for a two-surface
restoration. If billed
on a primary second
molar, the agency
will reimburse at the
rate for a three-
surface restoration.
On-line Fee
Schedules
Dental-Related Services
- 28 -
Crowns – single restorations only
The agency covers:
The following indirect crowns once every five years, per tooth, for permanent anterior
teeth for clients 15 through 20 years of age when the crowns meet prior authorization
(PA) criteria in Prior Authorization and the provider follows the PA requirements on the
following page:
Porcelain/ceramic crowns to include all porcelains, glasses, glass-ceramic, and
porcelain fused to metal crowns
Resin crowns and resin metal crowns to include any resin-based composite, fiber,
or ceramic reinforced polymer compound
Note: The agency does not cover permanent anterior crowns for clients through
14 years of age.
Payment
The agency considers the following to be included in the payment for a crown:
Tooth and soft tissue preparation
Amalgam and resin-based composite restoration, or any other restorative material placed
within six months of the crown preparation
Exception: The agency covers a one-surface restoration on an endodontically
treated tooth, or a core buildup or case post and core.
Temporaries, including but not limited to, temporary restoration, temporary crown,
provisional crown, temporary prefabricated stainless steel crown, ion crown, or acrylic
crown
Packing cord placement and removal
Diagnostic or final impressions
Crown seating (placement), including cementing and insulating bases
Occlusal adjustment of crown or opposing tooth or teeth
Local anesthesia
Dental-Related Services
- 29 -
Billing
The agency requires a provider to bill for a crown only after delivery and seating of the crown,
not at the impression date.
Prior authorization
The agency requires the provider to submit the following with each PA request for
crowns:
X-rays to assess all remaining teeth
Documentation and identification of all missing teeth
Caries diagnosis and treatment plan for all remaining teeth, including a caries
control plan for clients with rampant caries
Pre- and post-endodontic treatment X-rays for requests on endodontically treated
teeth
Documentation supporting a five-year prognosis that the client will retain the
tooth or crown if the tooth is crowned
CDT
Code
Description
PA?
Requirements
Age
Limitation
Maximum
Allowable Fee
D2710
crown – resin-based
composite (indirect)
Y
Tooth designation
required
Clients 15 to
20 years of
age only
On-line Fee
Schedule
D2720
crown – resin with
high noble metal
Y
Tooth designation
required
Clients 15 to
20 years of
age only
D2721
crown – resin with
predominantly base
metal
Y
Tooth designation
required
Clients 15 to
20 years of
age only
D2722
crown – resin with
noble metal
Y
Tooth designation
required
Clients 15 to
20 years of
age only
D2740
crown –
porcelain/ceramic
substrate
Y
Tooth designation
required
Clients 15 to
20 years of
age only
D2750
crown – porcelain
fused to high noble
metal
Y
Tooth designation
required
Clients 15 to
20 years of
age only
Dental-Related Services
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CDT
Code
Description
PA?
Requirements
Age
Limitation
Maximum
Allowable Fee
D2751
crown – porcelain
fused to
predominantly base
metal
Y
Tooth designation
required
Clients 15 to
20 years of
age only
D2752
crown – porcelain
fused to noble metal
Y
Tooth designation
required
Clients 15 to
20 years of
age only
Note: The agency does not pay for procedure codes D2710 through D2752 when
billed for posterior teeth.
Other restorative services
The agency covers:
All recementations of permanent indirect crowns.
Prefabricated stainless steel crowns, including stainless steel crowns with resin window,
resin-based composite crowns (direct), prefabricated esthetic coated stainless steel
crowns, and prefabricated resin crowns for primary anterior teeth once every three years
only for clients 20 years of age and younger as follows:
For clients 12 years of age and younger without PA if the tooth requires a four or
more surface restoration
For clients 13 through 20 years of age with PA (X-ray justification is required)
Prefabricated stainless steel crowns, including stainless steel crowns with resin window,
resin-based composite crowns (direct), prefabricated esthetic coated stainless steel
crowns, and prefabricated resin crowns for primary posterior teeth once every three years
without PA if:
Decay involves three or more surfaces for a primary first molar.
Decay involves four or more surfaces for a primary second molar.
The tooth had a pulpotomy.
X-ray justification is required.
Prefabricated stainless steel crowns, including stainless steel crowns with resin window,
and prefabricated resin crowns for permanent posterior teeth excluding 1, 16, 17, and 32
once every 3 years, for clients 20 years of age and younger, without PA. X-ray
justification is required.
Dental-Related Services
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Prefabricated stainless steel crowns for clients of the Developmental Disabilities
Administration without PA. X-ray justification is required.
Core buildup, including pins, only on permanent teeth, only for clients 20 years of age
and younger, and only allowed in conjunction with crowns and when prior authorized.
For indirect crowns, prior authorization must be obtained from the agency at the same
time as the crown. Providers must submit pre- and post-endodontic treatment
radiographs to the agency with the authorization request for endodontically treated teeth.
Cast post and core or prefabricated post and core, only on permanent teeth, only for
clients 20 years of age and younger, and only when in conjunction with a crown and
when prior authorized.
CDT
Code
Description
PA?
Requirements
Age
Limitation
Maximum
Allowable Fee
D2910
recement inlay, onlay,
or partial coverage
restoration
N
Tooth designation
required
Clients 20
years of age
and younger
only
On-line Fee
Schedule
D2915
recement cast or
prefabricated post and
core
N
Tooth designation
required
Clients 20
years of age
and younger
only
D2920
recement crown
N
Tooth designation
required
D2929
prefabricated
porcelain/ceramic
crown – primary tooth
*
Tooth designation
required
Clients 20
years of age
and younger
only
* For clients 12 years of age and younger without PA if the tooth requires a four or more
surface restoration. For clients 13 through 20 years of age with PA. X-ray justification is
required.
Dental-Related Services
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CDT
Code
Description
PA?
Requirements
Age
Limitation
Maximum
Allowable Fee
D2930
prefabricated stainless
steel crown – primary
tooth
*
Tooth designation
required
Clients 20
years of age
and younger
only
On-line Fee
Schedule
D2931
prefabricated stainless
steel crown –
permanent tooth
N
Tooth designation
required
Clients 20
years of age
and younger
only
D2932
prefabricated resin
crown
N
Tooth designation
required
Clients 20
years of age
and younger
only
* For clients 12 years of age and younger without PA if the tooth requires a four or more
surface restoration. For clients 13 through 20 years of age with PA. X-ray justification is
required.
CDT
Code
Description
PA?
Requirements
Age
Limitation
Maximum
Allowable Fee
D2933
prefabricated stainless
steel crown with resin
window
N
Tooth designation
required
Clients 20
years of age
and younger
only
On-line Fee
Schedule
D2934
prefabricated esthetic
coated stainless steel
crown – primary tooth
N
Tooth designation
required
Clients 20
years of age
and younger
only
D2950
core buildup,
including any pins
when required
Y
Tooth designation
required
Clients 20
years of age
and younger
only
D2952
post and core in
addition to crown,
indirectly fabricated
Y
Tooth designation
required
Clients 20
years of age
and younger
only
D2954
prefabricated post and
core in addition to
crown
Y
Tooth designation
required
Clients 20
years of age
and younger
only
Dental-Related Services
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What endodontic services are covered?
(WAC 182-535-1086)
Pulp capping
The agency considers pulp capping to be included in the payment for the restoration, unless the
client meets the EPA criteria or is prior authorized.
CDT
Code
Description
PA?
Requirements
Age
Limitation
Maximum
Allowable Fee
D3120
pulp cap – indirect
(excluding final
restoration)
Y
Tooth designation
required
Clients 20
years of age
and younger
On-line Fee
Schedule
Pulpotomy/pulpal debridement
The agency covers:
Therapeutic pulpotomy on primary teeth only for clients 20 years of age and younger.
Pulpal debridement on permanent teeth only, excluding teeth 1, 16, 17, and 32.
The agency does not pay for pulpal debridement when performed with palliative treatment for
dental pain or when performed on the same day as endodontic treatment.
CDT
Code
Description
PA?
Requirements
Age
Limitation
Maximum
Allowable Fee
D3220
therapeutic pulpotomy
(excluding final
restoration) – removal
of pulp coronal to the
dentinocemental
junction and application
of medicament
N
Tooth designation
required
Clients 20
years of age
and younger
On-line Fee
Schedule
D3221
pulpal debridement,
permanent teeth
N
Tooth designation
required
Dental-Related Services
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Endodontic treatment on primary teeth
The agency covers endodontic treatment with resorbable material for primary teeth if the entire
root is present at treatment.
CDT
Code
Description
PA?
Requirements
Maximum
Allowable Fee
D3230
pulpal therapy (resorbable
filling)-anterior, primary
N
Tooth designation
required
On-line Fee
Schedule
D3240
pulpal therapy (resorbable
filling) – posterior, primary
tooth (excluding final
restorations)
N
Tooth designation
required
Endodontic treatment on permanent teeth
The agency:
Covers endodontic treatment for permanent anterior teeth for all clients.
Covers endodontic treatment for permanent bicuspid and molar teeth, excluding teeth 1,
16, 17, and 32 for clients 20 years of age and younger.
Considers the following included in endodontic treatment:
Pulpectomy when part of root canal therapy
All procedures necessary to complete treatment
All intra-operative and final evaluation radiographs (X-rays) for the endodontic
procedure
Pays separately for the following services that are related to the endodontic treatment:
Initial diagnostic evaluation
Initial diagnostic radiographs
Post treatment evaluation radiographs if taken at least three months after
treatment
Dental-Related Services
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CDT
Code
Description
PA?
Requirements
Age
Limitation
Maximum
Allowable Fee
D3310
anterior
(excluding final
restoration)
N
Tooth designation
required
On-line Fee
Schedule
D3320
bicuspid (excluding final
restoration)
N
Tooth designation
required
Client 20
years of age
and younger
D3330
molar (excluding final
restoration)
N
Tooth designation
required
Clients 20
years of age
and younger
Endodontic retreatment on permanent teeth
The agency:
Covers endodontic retreatment for a client 20 years of age or younger when prior
authorized.
Covers endodontic retreatment of permanent anterior teeth for a client 21 years of age
and older when prior authorized.
Considers endodontic retreatment to include:
The removal of post(s), pin(s), old root canal filling material, and all procedures
necessary to prepare the canals.
Placement of new filling material.
Retreatment for permanent anterior, bicuspid, and molar teeth, excluding teeth 1,
16, 17, and 32.
Pays separately for the following services that are related to the endodontic retreatment:
Initial diagnostic evaluation
Initial diagnostic X-rays
Post treatment evaluation X-rays if taken at least three months after treatment
Does not pay for endodontic retreatment when provided by the original treating provider
or clinic unless prior authorized by the agency.
Dental-Related Services
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CDT
Code
Description
PA?
Requirements
Age
Limitation
Maximum
Allowable Fee
D3346
retreatment of previous
root canal therapy –
anterior
Y
Tooth designation
required.
All ages
On-line Fee
Schedule
D3347
retreatment of previous
root canal therapy –
bicuspid
Y
Tooth designation
required.
Clients age 20
and younger
D3348
retreatment of previous
root canal therapy –
molar
Y
Tooth designation
required.
Clients age 20
and younger
Apexification/apicoectomy
The agency covers:
Apexification for apical closures for anterior permanent teeth only on a case-by-case
basis and when prior authorized. Apexification is limited to the initial visit and three
medication replacements and limited to clients 20 years of age and younger, per tooth.
Apicoectomy and a retrograde filling for anterior teeth only for clients 20 years of age
and younger.
CDT
Code
Description
PA?
Requirements
Age
Limitation
Maximum
Allowable
Fee
D3351
apexification/recalcificat
ion – initial visit (apical
closure/calcific repair of
perforations, root
resorption, etc.)
Y
Tooth designation
required
Clients age 20
and younger
On-line Fee
Schedule
D3352
apexification/recalcificat
ion – interim medication
replacement (apical
closure/calcific repair of
perforations, root
resorption, etc.)
Y
Tooth designation
required
Clients age 20
and younger
D3410
apicoectomy anterior
N
Tooth designation
required
Clients age 20
and younger
D3430
retrograde filling – per
root
N
Tooth designation
required
Clients age 20
and younger
Dental-Related Services
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What periodontic services are covered?
(WAC 182-535-1088)
Surgical periodontal services
The agency covers the following, including all postoperative care:
Gingivectomy/gingivoplasty (does not include distal wedge procedures on erupting
molars), for clients 20 years of age and younger only, on a case-by-case basis, and when
prior authorized
Gingivectomy/gingivoplasty (does not include distal wedge procedures on erupting
molars) for clients of the Developmental Disabilities Administration
CDT
Code
Description
PA?
Requirements
Age Limitation
Maximum
Allowable Fee
D4210
gingivectomy or
gingivoplasty – four or
more contiguous teeth
or bounded teeth spaces
per quadrant
Y
Quadrant
designation
required
Clients age 20
and younger
On-line Fee
Schedule
D4211
gingivectomy or
gingivoplasty – one to
three contiguous teeth
or bounded teeth spaces
per quadrant
Y
Quadrant
designation
required
Clients age 20
and younger
Nonsurgical periodontal services
The agency:
Covers periodontal scaling and root planing for the number of teeth scaled that are
periodontically involved once per quadrant, for clients from 13 through 18 years of age,
per client in a two-year period on a case-by-case basis, when prior authorized, and only
when:
The client has X-ray evidence of periodontal disease and subgingival calculus.
The client's record includes supporting documentation for the medical necessity
of the service, including complete periodontal charting and a definitive diagnosis
of periodontal disease.
The client's clinical condition meets current published periodontal guidelines.
Dental-Related Services
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Performed at least two years from the date of completion of periodontal scaling
and root planing or surgical periodontal treatment, or at least 12 calendar months
from the completion of periodontal maintenance.
Covers periodontal scaling and root planing once per quadrant, per client, in a two-year
period for clients ages 19 years of age and older and only when:
The client has X-ray evidence of periodontal disease and subgingival calculus.
The client's record includes supporting documentation for the medical necessity,
including complete periodontal charting and a definitive diagnosis of periodontal
disease.
The client's clinical condition meets current published periodontal guidelines.
Performed at least two years from the date of completion of periodontal scaling
and root planing or surgical periodontal treatment.
Considers ultrasonic scaling, gross scaling, or gross debridement to be included in the
procedure and not a substitution for periodontal scaling and root planing.
Covers periodontal scaling and root planing only when the services are not performed on
the same date of service as prophylaxis, periodontal maintenance, gingivectomy, or
gingivoplasty.
Covers periodontal scaling and root planing for clients of the DDA.
Covers periodontal scaling and root planing, one time per quadrant in a 12-month period
for clients residing in a nursing facility.
Dental-Related Services
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CDT
Code
Description
PA?
Requirements
Age
Limitations
Maximum
Allowable Fee
D4341
periodontal scaling and
root planing – four or
more teeth per quadrant
Y
Quadrant
designation required
Clients 13
through 18
years of age
only
On-line Fee
Schedule
D4341
periodontal scaling and
root planing – four or
more teeth per quadrant
N
Quadrant
designation required
Clients 19
years of age
and older
only
D4342
periodontal scaling and
root planing – one to
three teeth per quadrant
Y
Quadrant
designation required
Clients 13
through 18
years of age
only
D4342
periodontal scaling and
root planing – one to
three teeth per quadrant
N
Quadrant
designation required
Clients 19
years of age
and older
only
D4355
Full mouth debridement
to enable
comprehensive
evaluation and
diagnosis
N
Covered only for
clients of the
Developmental
Disabilities
Administration of
DSHS
No age
limitations
Periodontal maintenance
The agency:
Covers periodontal maintenance for clients from 13 through 18 years of age, once per
client in a 12-month period on a case-by-case basis, when prior authorized, and only
when:
The client has X-ray evidence of periodontal disease.
The client's record includes supporting documentation for the medical necessity,
including complete periodontal charting with location of the gingival margin and
clinical attachment loss and a definitive diagnosis of periodontal disease.
The client's clinical condition meets current published periodontal guidelines.
Dental-Related Services
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The client has had periodontal scaling and root planing but not within 12 months
of the date of completion of periodontal scaling and root planing, or surgical
periodontal treatment.
Dental-Related Services
- 41 -
Covers periodontal maintenance once per client in a 12 month period for clients 19 years
of age and older only when:
The client has X-ray evidence of periodontal disease.
The client's record includes supporting documentation for the medical necessity,
including complete periodontal charting and a definitive diagnosis of periodontal
disease.
The client's clinical condition meets current published periodontal guidelines.
The client has had periodontal scaling and root planing after but not within 12
months from the date of completion of periodontal scaling and root planing, or
surgical periodontal treatment.
Covers periodontal maintenance only if performed at least 12 calendar months after
receiving prophylaxis, periodontal scaling and root planing, gingivectomy, or
gingivoplasty.
Covers periodontal maintenance for clients of DDA.
Covers periodontal maintenance for clients residing in a nursing facility:
Periodontal maintenance (four quadrants) substitutes for an eligible periodontal
scaling or root planing once every six months
Periodontal maintenance allowed six months after scaling or root planing
CDT
Code
Description
PA?
Age
Limitations
Maximum
Allowable Fee
D4910
periodontal maintenance
Y
Clients 13 through 18
years of age only
On-line Fee
Schedules
D4910
periodontal maintenance
N
Clients 19 years of age
and older only
On-line Fee
Schedules
Dental-Related Services
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What prosthodontic (removable) services are
covered?
(WAC 182-535-1090)
Complete dentures
The agency covers:
A complete denture, including an overdenture, when prior authorized and meets the
agency’s coverage criteria.
Three-month post-delivery care (e.g., adjustments, soft relines, and repairs) from the
delivery (placement) date of the complete denture. This is considered part of the
complete denture procedure and is not paid separately.
Complete dentures, which are limited to:
One initial maxillary complete denture and one initial mandibular complete
denture per client, per the client’s lifetime.
One replacement maxillary complete denture and one replacement mandibular
complete denture per client, per the client’s lifetime.
Replacement of a complete denture or overdenture only if prior authorized, and only if
the replacement occurs at least five years after the seat date of the complete denture or
overdenture being replaced. The replacement denture must be prior authorized.
CDT
Code
Description
PA?
Maximum Allowable Fee
D5110
complete denture – maxillary
Y*
On-line Fee Schedule
D5120
complete denture – mandibular
Y*
*See prior authorization for prosthodontic and prosthodontic-related services.
The provider must obtain a signed Denture or Partial Denture Agreement of Acceptance form,
HCA 13-809, from the client at the conclusion of the final denture try-in for an agency-
authorized complete denture. If the client abandons the complete denture after signing the
agreement of acceptance, the agency will deny subsequent requests for the same type of dental
prosthesis if the request occurs prior to the dates specified in this section. A copy of the signed
agreement must be kept in the provider’s files and be available upon request by the agency.
Dental-Related Services
- 43 -
Resin Partial Dentures
The agency:
Covers a partial denture for anterior and posterior teeth when the partial denture meets
the agency coverage criteria for resin partial dentures.
Requires prior authorization for partial dentures.
Considers three-month post-delivery care (e.g., adjustments, soft relines, and repairs)
from the delivery (placement) date of the partial denture as part of the partial denture
procedure. This is not paid separately.
Covers replacement of a resin-based denture with any prosthetic, only if prior authorized
and is at least three years after the delivery (placement) date of the resin partial denture
being replaced. The replacement denture must be prior authorized and meet the agency’s
coverage criteria for resin partial dentures.
Coverage criteria for resin partial dentures
A partial denture, including a resin partial denture, is covered for anterior and posterior teeth
when the partial denture meets the following agency coverage criteria:
The remaining teeth in the arch must have a reasonable periodontal diagnosis and
prognosis.
The client has established caries control.
Only if one or more anterior teeth are missing or four or more posterior teeth (excluding
teeth 1, 2, 15, 16, 17, 18, 31, and 32). Pontics on an existing fixed bridge do not count as
missing teeth.
There are a minimum of four stable teeth remaining per arch.
There is a three-year prognosis for retention of the remaining teeth.
CDT
Code
Description
PA?
Limitations
Maximum
Allowable Fee
D5211
maxillary partial denture – resin
base (including any conventional
clasps, rests and teeth)
Y*
On-line Fee
Schedule
D5212
mandibular partial denture – resin
base (including any conventional
clasps, rests and teeth)
Y*
*See prior authorization for prosthodontic and prosthodontic-related services.
Dental-Related Services
- 44 -
Other requirements/limitations
The agency:
Does not cover replacement of a cast metal framework partial denture, with any type of
denture, within five years of the initial delivery (placement) date of the partial denture.
Requires a provider to bill for removable partial or complete denture only after the
delivery of the prosthesis, not at the impression date. The agency may pay for lab fees if
the removable partial or complete denture is not delivered and inserted.
Requires a provider to deliver services and procedures that are of acceptable quality to
the agency. The agency may recoup payment for services that are determined to be
below the standard of care or of an unacceptable product quality.
Adjustments to dentures
Adjustments to complete and partial dentures are included in the global fee for the denture for
the first 90 days after the seat date.
CDT
Code
Description
PA?
Maximum
Allowable Fee
D5410
adjust complete denture – maxillary
N
On-line Fee
Schedule
D5411
adjust complete denture – mandibular
N
D5421
adjust partial denture – maxillary
N
D5422
adjust partial denture – mandibular
N
Repairs to complete and partial dentures
The agency covers repairs to complete and partial dentures once in a 12-month period, per arch.
The cost of repairs cannot exceed the cost of a replacement denture or a partial denture. The
agency covers additional repairs on a case-by-case basis and when prior authorized.
CDT
Code
Description
PA?
Requirements
Maximum
Allowable Fee
D5510
repair broken complete denture
base
N
Arch designation
required
On-line Fee
Schedules
D5520
replace missing or broken teeth
– complete denture (each tooth)
N
Tooth designation
required
D5620
repair cast framework
N
Arch designation
required
D5650
add tooth to existing partial
denture
N
Tooth designation
required
Dental-Related Services
- 45 -
CDT
Code
Description
PA?
Requirements
Maximum
Allowable Fee
D5660
add clasp to existing partial
denture
N
Tooth designation
required
Denture rebase procedures
The agency covers a laboratory rebase to a complete or partial denture once in a three-year
period when performed at least six months after the seating date. An additional rebase may be
covered for complete or partial dentures on a case-by-case basis when prior authorized.
CDT
Code
Description
PA?
Maximum
Allowable Fee
D5710
rebase complete maxillary denture
N
On-line Fee
Schedules
D5711
rebase complete mandibular denture
N
D5720
rebase maxillary partial denture
N
D5721
rebase mandibular partial denture
N
Note: The agency does not allow a denture rebase and a reline in the same three-
year period. The agency covers rebases or relines only on partials and complete
dentures (CDT codes D5110, D5120, D5211, D5212, D5213, and D5214).
Denture reline procedures
The agency covers a laboratory reline to a complete or partial denture once in a three-year period
when performed at least six months after the delivery (placement) date. An additional reline may
be covered for complete or partial dentures on a case-by-case basis when prior authorized.
CDT
Code
Description
PA?
Maximum
Allowable Fee
D5750
reline complete maxillary denture (laboratory)
N
On-line Fee
Schedules
D5751
reline complete mandibular denture (laboratory)
N
D5760
reline maxillary partial denture (laboratory)
N
D5761
reline mandibular partial denture (laboratory)
N
Note: The agency does not allow a denture rebase and a reline in the same three-
year period. The agency covers rebases or relines only on partials and complete
dentures (CDT codes D5110, D5120, D5211, D5212, D5213, and D5214).
Dental-Related Services
- 46 -
Other removable prosthetic services
The agency:
Covers up to two tissue conditionings, for a client 20 years of age or younger, and only
when performed within three months after the delivery (placement) date.
Covers laboratory fees, subject to the following:
The agency does not pay separately for laboratory or professional fees for
complete and partial dentures.
The agency may pay part of billed laboratory fees when the provider obtains PA,
and the client:
Is not eligible at the time of delivery of the partial or complete denture.
Moves from the state.
Cannot be located.
Does not participate in completing the partial or complete dentures.
Dies.
Note: Use the impression date as the date of service in the above instance.
Requires providers to submit copies of laboratory prescriptions and receipts or invoices
for each claim when submitting for prior authorization of code D5899 for laboratory fees.
CDT
Code
Description
PA?
Requirements
Age
Limitations
Maximum
Allowable Fee
D5850
tissue conditioning,
maxillary
N
Clients 20
years of age
and younger
only
On-line Fee
Schedule
D5851
tissue conditioning,
mandibular
N
Clients 20
years of age
and younger
only
D5863
overdenture –
complete maxillary
Y
Arch designation
required
D5865
overdenture –
complete mandibular
Y
Arch designation
required
D5899
unspecified removable
prosthodontic
procedure, by report
Y
Arch designation
required
D6930
recement fixed partial
denture
Y
Arch or quadrant
designation required
Dental-Related Services
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Prior authorization for removable prosthodontic and
prosthodontic-related procedures
The agency requires prior authorization (PA) for the removable prosthodontic and prosthodontic-
related procedures listed in this section when noted. Documentation supporting the medical
necessity for the service must be included in the client's file. PA requests must meet the prior
authorization criteria. In addition, the agency requires the dental provider to submit:
Appropriate and diagnostic X-rays of all remaining teeth.
A dental record which identifies:
All missing teeth for both arches.
Teeth that are to be extracted.
Dental and periodontal services completed on all remaining teeth.
Note: If a client wants to change denture providers, the agency must receive a
statement from the client requesting the provider change. The agency will check
to make sure services haven’t already been rendered by the original provider
before cancelling the original authorization request for services. The new
provider must submit another authorization request for services.
For complete dentures or resin partials:
X-rays if teeth are present. The exception is for nursing facility clients when X-
rays are unavailable. In this case, the provider must submit a completed Tooth
Chart, HCA 13-863 form.
If edentulous, a complete Tooth Chart, HCA 13-863 form.
The tooth chart must be completed as follows: missing teeth must be marked with an | |
and those teeth to be extracted must be marked with an X.
The agency requires a provider to:
Obtain a signed Denture or Partial Denture Agreement of Acceptance form, HCA 13-
809, from the client at the conclusion of the final denture try-in for an agency-authorized
complete denture or a cast-metal denture described in this section. If the client abandons
the complete or partial denture after signing the agreement of acceptance, the agency will
deny subsequent requests for the same type of dental prosthesis if the request occurs prior
to the time limitations specified in this section.
Retain in the client’s record the completed copy of the signed Denture or Partial Denture
Agreement of Acceptance form, HCA 13-809, that documents the client’s acceptance of
the dental prosthesis.
Dental-Related Services
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Alternative living facilities
The agency requires a provider to submit the following with a PA request for a
removable partial or complete denture for a client residing in an alternative living facility
or in a nursing facility, group home, or other facility:
The client's medical diagnosis or prognosis
The attending physician's signature documenting medical necessity for the
prosthetic service
The attending dentist's or denturist's signature documenting medical necessity for
the prosthetic service
A written and signed consent for treatment from the client's legal guardian when a
guardian has been appointed
A completed copy of the Denture/Partial Appliance Request for Skilled Nursing
Facility Client form, HCA 13-788
The agency limits removable partial dentures to resin-based partial dentures for all clients
residing in a nursing facility. The agency may consider cast metal partial dentures if
coverage criteria are met.
What maxillofacial prosthetic services are
covered?
(WAC 182-535-1092)
The agency:
Covers maxillofacial prosthetics only for clients 20 years of age and younger, on a case-
by-case basis and when prior authorized.
Must pre-approve a provider qualified to furnish maxillofacial prosthetics.
Dental-Related Services
- 49 -
What oral and maxillofacial surgery services are
covered?
(WAC 182-535-1094)
General coverage
All coverage limitations and age requirements apply to clients of the Developmental Disabilities
Administration unless otherwise noted.
Agency-enrolled dental providers who are not specialized to perform oral and
maxillofacial surgery must use only the current dental terminology (CDT) codes to bill
claims for services that are listed as covered.
Agency-enrolled dental providers who are specialized to perform oral and maxillofacial
surgery can bill using Current Procedural Terminology (CPT) codes unless the procedure
is specifically listed in this provider guide as a CDT covered code (e.g., extractions).
Note: For billing information on billing CPT codes for oral surgery, refer to the
agency’s current Physician-Related Services/Health Care Professional Provider
Guide. The agency pays oral surgeons for only those CPT codes listed in the
Dental Fee Schedule under Dental CPT Codes.
Covers nonemergency oral surgery performed in a hospital or ambulatory surgery center
only for:
Clients 8 years of age and younger.
Clients from 9 through 20 years of age only on a case-by-case basis and when the
site-of-service is prior authorized by the agency.
Clients any age of the Developmental Disabilities Administration.
Requires the dental provider to submit all of the following for site-of-service and oral
surgery CPT codes that require PA:
Documentation used to determine medical appropriateness
Cephalometric films
Radiographs (X-rays)
Photographs
Written narrative/letter of medical necessity
Dental-Related Services
- 50 -
Services exempt from site of service prior authorization
The agency does not require site-of-service authorization for any of the following surgeries:
Cleft palate surgeries (CPTs 42200, 42205, 42210, 42215, 42225, 42226, 42227, 42235, 42260,
42280, and 42281) with a diagnosis of cleft palate.
Documentation requirements
The agency requires the client’s dental record to include supporting documentation for each type
of extraction or any other surgical procedure billed to the agency. The documentation must
include:
Appropriate consent form signed by the client or the client’s legal representative.
Appropriate radiographs.
Medical justification with diagnosis.
The client’s blood pressure, when appropriate.
A surgical narrative and complete description of each service performed beyond surgical
extraction or beyond code definition.
A copy of the post-operative instructions.
A copy of all pre- and post-operative prescriptions.
Extractions and surgical extractions
The agency:
Covers routine and surgical extractions (includes local anesthesia, suturing (if needed),
alveoloplasty and tori removal (if needed), and routine postoperative care). 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
Covers unusual, complicated surgical extractions with prior authorization.
Covers surgical extraction of unerupted teeth.
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Covers debridement of a granuloma or cyst that is five millimeters or greater in diameter.
The agency includes debridement of a granuloma or cyst that is less than five millimeters
as part of the global fee for the extraction.
Note: For surgical extractions, documentation supporting the medical necessity
of the billed procedure code must be in the client’s record.
Code
Description
PA?
Requirements
Maximum
Allowable
Fee
D7111
extraction, coronal remnants –
deciduous tooth
N
Tooth designation
required
On-line
Fee
Schedule
D7140
extraction, erupted tooth or
exposed root (elevation and/or
forceps removal)
N
Tooth designation
required
D7210
surgical removal of erupted
tooth requiring elevation of
mucoperiosteal flap and removal
of bone and/or section of tooth
N
Tooth designation
required
D7220
removal of impacted tooth – soft
tissue
N
Tooth designation
required
D7230
removal of impacted tooth –
partially bony
N
Tooth designation
required
D7240
removal of impacted tooth –
completely bony
N
Tooth designation
required
D7241
removal of impacted tooth –
completely bony, with unusual
surgical complications
Y
Tooth designation
required
D7250
surgical removal of residual
tooth roots (cutting procedure)
*
Tooth designation
required
*This service must be prior authorized by the agency if provided by the original treating provider
or clinic.
Other surgical procedures
The agency:
Covers tooth reimplantation/stabilization of accidentally evulsed or displaced teeth.
Covers the following without prior authorization:
Biopsy of soft oral tissue
Brush biopsy
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Requires providers to keep all biopsy reports or finding in the client’s dental record.
Code
Description
PA?
Requirements
Age
Limitations
Maximum
Allowable
Fee
D7270
tooth reimplantation
and/or stabilization of
accidentally evulsed or
displaced tooth
N
On-line Fee
Schedule
D7280
surgical access of an
unerupted tooth
Y
Tooth designation
required
Clients 20 years
of age and
younger only
D7283
placement of device to
facilitate eruption of
impacted tooth
Y
Covered in
conjunction with
D7280 and when
medically necessary
Clients 20 years
of age and
younger only
D7285
biopsy of oral tissue –
Hard
Y
Retroactive to dates
of service on and
after March 1, 2012
Code
Description
PA?
Requirements
Age
Limitations
Maximum
Allowable
Fee
D7286
biopsy of oral tissue –
soft
N
D7288
brush biopsy –
transepithelial sample
collection
N
Alveoloplasty – surgical preparation of ridge for dentures
The agency covers alveoplasty on a case-by-case basis when prior authorized and not performed
in conjunction with extractions. Photos or radiographs (X-rays), as appropriate, must be
submitted to the agency with the prior authorization request.
Code
Description
PA?
Requirements
Maximum
Allowable Fee
D7320
alveoloplasty not in
conjunction with extractions
– four or more teeth, per
quadrant
Y
Quadrant
designation
required
On-line Fee
Schedule
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Surgical excision of soft tissue lesions
The agency covers surgical excision of soft tissue lesions only on a case-by-case basis and when
prior authorized. Photos or radiographs (X-rays), as appropriate, must be submitted to the
agency with the prior authorization request.
Code
Description
PA?
Requirements
Maximum
Allowable Fee
D7410
excision of benign lesion up to
1.25 cm
Y
Quadrant
designation
required
On-line Fee
Schedule
Excision of bone tissue
The agency covers only the following excisions of bone tissue in conjunction with placement of
immediate, complete, or partial dentures, when prior authorized. Photos or radiographs, as
appropriate, must be submitted to the agency with the prior authorization request.
Removal of lateral exostosis
Removal of mandibular or palatal tori
Surgical reduction of osseous tuberosity
Code
Description
PA?
Requirements
Age
Limitations
Maximum
Allowable Fee
D7471
removal of lateral
exostosis (maxilla or
mandible)
Y
Arch designation
required
On-line Fee
Schedule
D7472
removal of torus
palatinus
Y
D7473
removal of torus
mandibularis
Y
D7485
surgical reduction of
osseous tuberosity
Y
Quadrant
designation
required
D7970
excision of
hyperplastic tissue –
per arch
Y
Clients 20 years
of age and
younger only
D7971
excision of pericoronal
gingiva
Y
Clients 20 years
of age and
younger only
D7972
surgical reduction of
fibrous tuberosity
Y
Clients 20 years
of age and
younger only
Dental-Related Services
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Surgical incision
The agency:
Covers uncomplicated dental-related intraoral and extraoral soft tissue incision and
drainage of abscess. The agency does not cover this service when combined with an
extraction or root canal treatment. Documentation supporting medical necessity must be
in the client's record.
Note: Providers must not bill drainage of abscess (D7510 or D7520) in
conjunction with palliative treatment (D9110).
Covers removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue when
prior authorized. Documentation supporting the medical necessity for the service must
be in the client's record.
Covers frenuloplasty/frenulectomy for clients 6 years of age and younger, without prior
authorization.
Covers frenuloplasty/frenulectomy for clients from 7 to 12 years of age only on a case-
by-case basis and when prior authorized. Photos must be submitted to the agency with
the prior authorization request.
Requires documentation supporting the medical necessity, including photographs, for the
service to be in the client's record.
Code
Description
PA?
Requirements
Age
Limitations
Maximum
Allowable Fee
D7510
incision and drainage
of abscess – intraoral
soft tissue
N
On-line Fee
Schedule
D7520
incision and drainage
of abscess – extraoral
soft tissue
N
D7530
removal of foreign
body from mucosa,
skin, or subcutaneous
alveolar tissue
Y
D7960
frenulectomy
(frenectomy or
frenotomy) – separate
procedure
Y
Arch designation
required.
Clients 7 to 12
years of age
only.
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Code
Description
PA?
Requirements
Age
Limitations
Maximum
Allowable Fee
D7960
frenulectomy
(frenectomy or
frenotomy) – separate
procedure
N
Arch designation
required.
Clients six
years of age
and younger
only.
On-line Fee
Schedule
D7963
Frenuloplasty
Y
Arch designation
required.
Clients 7 to 12
years of age
only.
D7963
Frenuloplasty
N
Arch designation
required.
Clients six
years of age
and younger
only.
Occlusal orthotic devices
The agency covers:
Occlusal orthotic devices for clients from 12 through 20 years of age only on a case-by-
case basis and when prior authorized.
An occlusal orthotic device only as a laboratory processed full arch appliance.
Note: Refer to What adjunctive general services are covered for occlusal guard
coverage and limitations on coverage.
Code
Description
PA?
Age
Limitations
Maximum
Allowable Fee
D7880
occlusal orthotic device, by report
Y
Clients 12
through 20
years of age
only.
On-line Fee
Schedules
What orthodontic services are covered?
(WAC 182-535-1096)
The agency covers orthodontic services, subject to the coverage limitations listed, for clients 20
years of age and younger according to the agency’s current Orthodontic Services Provider Guide.
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What adjunctive general services are covered?
(WAC 182-535-1098)
Palliative treatment
The agency covers palliative (emergency) treatment, not to include pulpal debridement (D3221),
for treatment of dental pain, limited to once per day, per client, as follows:
The treatment must occur during limited evaluation appointments
A comprehensive description of the diagnosis and services provided must be documented
in the client's record
Appropriate radiographs must be in the client's record supporting the medical necessity of
the treatment
Palliative treatment is not allowed on same day as definitive treatment.
Code
Description
PA?
Requirement
Maximum Allowable
Fee
D9110
palliative (emergency) treatment
of dental pain – minor procedure
N
Tooth
designation
required
On-line Fee Schedule
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Anesthesia
The agency:
Covers local anesthesia and regional blocks as part of the global fee for any procedure
being provided to clients.
The provider's current Department of Health (DOH) anesthesia permit must be on file
with the agency.
Covers office-based oral or parenteral conscious sedation, deep sedation, or general
anesthesia, as follows:
ANESTHESIA PRIOR AUTHORIZATION
Type
Ages
PA?
General anesthesia
(Performed in office setting
only)
0 through 8 years of age
Any age clients of DDA
No
9 through 20 years of age
Yes*
9 through 20 years of age with
diagnosis of cleft palate
No
21 years of age and older
Yes
Oral conscious sedation
(Office-based)
0 through 20 years of age
Any age clients of DDA
No
21 years of age and older
Yes
Parenteral conscious
sedation (Office-based)
0 through 20 years of age
Any age clients of DDA
No
21 years of age and older
Yes
*Unless providing one of the services listed in WAC 182-535-1094(1)(f)-(m).
Note: Letters of medical necessity for anesthesia must clearly describe the
medical need for anesthesia and what has been tried and failed. Dental phobia
and fear of needles is not specific enough information.
Covers administration of nitrous oxide for clients once per day.
Requires providers of oral or parenteral conscious sedation, deep sedation, or general
anesthesia to meet:
The prevailing standard of care.
The provider's professional organizational guidelines.
The requirements in Chapter 246-817 WAC.
Relevant Department of Health (DOH) medical, dental, or nursing anesthesia
regulations.
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Requires providers to bill anesthesia services using the CDT codes listed in the table
below.
Pays for anesthesia services according to WAC 182-535-1350.
Code
Description
PA?
Maximum
Allowable Fee
D9220
deep sedation/general anesthesia–first 30
minutes
See
Anesthesia
Prior
Authorization
Table
On-line Fee
Schedule
D9221
deep sedation/general anesthesia—each
additional 15 minutes
D9230
analgesia, anxiolysis, inhalation of nitrous oxide
D9241
intravenous conscious sedation/analgesia-first
30 minutes
D9242
Intravenous conscious sedation/analgesia—each
additional 15 minutes
D9248
non-intravenous conscious sedation
Billing for anesthesia
Billing time for anesthesia begins when the anesthesiologist or CRNA starts to physically
prepare the patient for the induction of anesthesia in the operating room area (or its
equivalent) and ends when the anesthesiologist or CRNA is no longer in constant
attendance (e.g., when the patient can be safely placed under post-operative supervision).
Bill for general anesthesia as follows:
Bill one unit of D9220 for the first 30 minutes of deep sedation/general anesthesia. Each
additional 15 minute increment of deep sedation/general anesthesia is equal to one unit of
D9221. For example: 60 minutes of general anesthesia would be billed as 1 unit of
D9220 and 2 units of D9221.
Bill for intravenous conscious sedation/analgesia as follows:
Bill one unit of D9241 for the first 30 minutes of conscious sedation/analgesia. Each
additional 15 minute increment of intravenous conscious sedation/analgesia is equal to
one unit of D9242. For example: 60 minutes of intravenous conscious
sedation/analgesia would be billed as 1 unit of D9241 and 2 units of D9242.
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Professional visits and consultations
The agency:
Covers professional consultation or diagnostic services only when provided by a
dentist or a physician other than the practitioner providing treatment.
Requires the client to be referred by the agency for the services.
Covers up to two house/extended care facility calls (visits) per facility, per
provider. The agency limits payment to two facilities per day, per provider.
Covers one hospital call (visit), including emergency care, per day, per provider,
per client, and not in combination with a surgical code unless the decision for
surgery is a result of the visit.
Covers emergency office visits after regularly scheduled hours. The agency limits
payment to one emergency visit per day, per client, per provider.
Code
Description
PA?
Maximum
Allowable Fee
D9410
house/extended care facility call
N
On-line Fee
Schedule
D9420
hospital call
N
D9440
office visit – after regularly scheduled hours
N
When billing for evaluation and management (E/M) codes, all of the following must be
true:
Services must be billed on an 837P HIPAA compliant claim form, Professional
claim via the Direct Data Entry (DDE) system, or a paper CMS-1500.
Services must be billed using one of the following CPT procedure codes and
modifiers must be used if appropriate.
E/M codes may not be billed for the same client, on the same day as surgery
unless the E/M visit resulted in the decision for surgery.
Code
Description
*Refer to CPT manual for long descriptions.
PA?
Maximum
Allowable Fee
99201
Office/outpatient visit, new*
N
On-line Fee
Schedules
99211
Office/outpatient visit, est*
N
99231
Subsequent hospital care*
N
99241
Office Consultation*
N
99251
Inpatient Consultation*
N
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Drugs
The agency covers drugs and/or medicaments (pharmaceuticals) such as antibiotics, steroids, or
anti-inflammatories, for therapeutic purposes for clients 20 years of age and younger.
The agency's Dental Program does not pay for oral sedation medications.
Code
Description
PA?
Maximum
Allowable Fee
D9610
therapeutic parenteral drug, single administration
N
On-line Fee
Schedule
D9612
therapeutic parenteral drugs, two or more
administrations, different medications
N
D9630
other drugs and/or medicaments, by report
N
Behavior management
The agency covers behavior management when the assistance of one additional dental staff other
than the dentist is required (documentation of medical necessity of the service must be included
in the client’s record) for:
Clients eight years of age and younger.
Clients from 9 through 20 years of age, only on a case-by-case basis and when prior
authorized.
Clients any age of the Developmental Disabilities Administration (DDA).
Clients who reside in an alternative living facility.
Clients diagnosed with autism.
Note: For clients residing in an alternative living facility, documentation
supporting the medical necessity of the billed procedure code must be in
the client’s record.
CDT
Code
Description
PA?
Age
Limitations
Maximum
Allowable Fee
D9920
behavior management
N
Clients 8 years of age
and younger and
any age for clients of
DDA, clients residing in
alternative living facility,
and clients diagnosed
with autism
On-line Fee Schedule
D9920
behavior management
Y
Clients 9 through 20
years of age
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Postsurgical complications
The agency covers treatment of post-surgical complications (e.g., dry socket). Documentation
supporting the medical necessity of the service must be in the client's record.
Code
Description
PA?
Requirement
Maximum
Allowable Fee
D9930
treatment of complications
(post-surgical) – unusual
circumstances
N
Tooth designation
required.
On-line Fee Schedule
Occlusal guards
The agency covers occlusal guards when medically necessary and prior authorized.
(See What oral and maxillofacial surgery services are covered? for occlusal orthotic device
coverage and coverage limitations.) The agency covers:
An occlusal guard only for clients from 12 through 20 years of age when the client has
permanent dentition.
An occlusal guard only as a laboratory processed full arch appliance.
Code
Description
PA?
Age Limitations
Maximum
Allowable Fee
D9940
occlusal guard, by report
Y
Clients 12
through 20 years
of age only.
On-line Fee
Schedules
Dental-Related Services
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What dental-related services are not covered?
(WAC 182-535-1100)
General – All ages
The agency does not cover:
The dental-related services listed under Noncovered Services by Category unless the
services include those medically necessary services and other measures provided to
correct or ameliorate conditions discovered during a screening performed under the early
periodic screening, diagnosis and treatment (EPSDT) program. When EPSDT applies,
the agency evaluates a noncovered service, equipment, or supply according to the process
in WAC 182-501-0165 to determine if it is medically necessary, safe, effective, and not
experimental.
Any service specifically excluded by statute.
More costly services when less costly, equally effective services as determined by the
agency are available.
Services, procedures, treatments, devices, drugs, or application of associated services:
That the agency or the Centers for Medicare and Medicaid Services (CMS)
considers investigative or experimental on the date the services were provided.
That are not listed as covered in one or both of the following:
Washington Administrative Code (WAC)
Agency’s current published documents
By category – For all ages
The agency does not cover the dental-related services listed under the following categories of
service for any age:
Diagnostic services
Detailed and extensive oral evaluations or reevaluations
Posterior-anterior or lateral skull and facial bone survey films
Any temporomandibular joint films
Tomographic surveys/3-D imaging
Viral cultures, genetic testing, caries susceptibility tests, or adjunctive prediagnostic tests
Comprehensive periodontal evaluations
Dental-Related Services
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Preventive services
Nutritional counseling for control of dental disease
Removable space maintainers of any type
Sealants placed on a tooth with the same-day occlusal restoration, preexisting occlusal
restoration, or a tooth with occlusal decay
Custom fluoride trays of any type
Bleaching trays
Restorative services
Restorations for wear on any surface of any tooth without evidence of decay through the
dentoenamel junction (DEJ) or on the root surface
Preventive restorations
Labial veneer resin or porcelain laminate restorations
Sedative fillings
Crowns and crown related services
Gold foil restorations
Metallic, resin-based composite, or porcelain/ceramic inlay/onlay restorations
Crowns for cosmetic purposes (e.g., peg laterals and tetracycline staining)
Permanent indirect crowns for posterior teeth
Permanent indirect crowns on permanent anterior teeth for clients 14 years of age
and younger
Temporary or provisional crowns (including ion crowns)
Any type of coping
Crown repairs
Crowns on teeth 1, 16, 17, and 32
Polishing or recontouring restorations or overhang removal for any type of restoration
Any services other than extraction on supernumerary teeth
Endodontic services
Indirect or direct pulp caps
Any endodontic therapy on primary teeth, except endodontic treatment with resorbable
material for primary maxillary incisor teeth D, E, F, and G, if the entire root is present at
treatment
Dental-Related Services
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Periodontic services
Surgical periodontal services including, but not limited to:
Gingival flap procedures
Clinical crown lengthening
Osseous surgery
Bone or soft tissue grafts
Biological material to aid in soft and osseous tissue regeneration
Guided tissue regeneration
Pedicle, free soft tissue, apical positioning, subepithelial connective tissue, soft
tissue allograft, combined connective tissue and double pedicle, or any other soft
tissue or osseous grafts
Distal or proximal wedge procedures
Nonsurgical periodontal services including, but not limited to:
Intracoronal or extracoronal provisional splinting
Full mouth or quadrant debridement (except for clients of the developmental
disabilities administration)
Localized delivery of chemotherapeutic agents
Any other type of nonsurgical periodontal service
Removable prosthodontics
Removable unilateral partial dentures
Any interim complete or partial dentures
Flexible base partial dentures
Any type of permanent soft reline (e.g., molloplast)
Precision attachments
Replacement of replaceable parts for semi-precision or precision attachments
Replacement of second or third molars for any removable prosthesis
Immediate dentures
Cast-metal framework partial dentures
Implant services
Any type of implant procedures, including, but not limited to, any tooth implant abutment
(e.g., periosteal implants, eposteal implants, and transosteal implants), abutments or
implant supported crowns, abutment supported retainers, and implant supported retainers
Any maintenance or repairs to the above implant procedures
The removal of any implant as described above
Dental-Related Services
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Fixed prosthodontics
Fixed partial denture pontic
Fixed partial denture retainer
Precision attachment, stress breaker, connector bar, coping, cast post, or any other type of
fixed attachment or prosthesis
Occlusal orthotic splint or device, bruxing or grinding splint or device,
temporomandibular joint splint or device, or sleep apnea splint or device
Oral maxillofacial prosthetic services
The agency does not cover any type of oral or facial prosthesis other than those listed in What
maxillofacial prosthetic services are covered?
Oral and maxillofacial surgery
Any oral surgery service not listed in What oral and maxillofacial surgery services are
covered?
Any oral surgery service that is not listed in the agency's list of covered current
procedural terminology (CPT) codes published in the agency's current rules or
Washington Apple Health provider guides
Vestibuloplasty
Adjunctive general services
Anesthesia, including, but not limited to:
Local anesthesia as a separate procedure
Regional block anesthesia as a separate procedure
Trigeminal division block anesthesia as a separate procedure
Medication for oral sedation, or therapeutic intramuscular (IM) drug injections,
including antibiotic and injection of sedative
Application of any type of desensitizing medicament or resin
Other general services including, but not limited to:
Fabrication of an athletic mouthguard
Nightguards
Occlusion analysis
Occlusal adjustment, tooth or restoration adjustment or smoothing, or
odontoplasties
Enamel microabrasion
Dental supplies such as toothbrushes, toothpaste, floss, and other take home items
Dentist's or dental hygienist's time writing or calling in prescriptions
Dentist's or dental hygienist's time consulting with clients on the phone
Educational supplies
Dental-Related Services
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Nonmedical equipment or supplies
Personal comfort items or services
Provider mileage or travel costs
Fees for no-show, canceled, or late arrival appointments
Service charges of any type, including fees to create or copy charts
Office supplies used in conjunction with an office visit
Teeth whitening services or bleaching, or materials used in whitening or
bleaching
Botox or derma-fillers
By Category – For clients 21 years of age and older only
The agency does not cover the dental-related services listed under the following categories of
service for clients 21 years of age and older only:
Diagnostic services
Occlusal intraoral radiographs
Diagnostic casts
Pulp vitality tests
Preventive services
Sealants (except for clients of the developmental disabilities administration)
Restorative services
Prefabricated resin crowns
Any type of core buildup, cast post and core, or prefabricated post and core
Endodontic services
Endodontic treatment on permanent bicuspids or molar teeth
Any apexification/recalcification procedures
Any apicoectomy/perioradicular surgical endodontic procedures including, but not
limited to, retrograde fillings (except for anterior teeth), root amputation, reimplantation,
and hemisections
Dental-Related Services
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Adjunctive general services
Occlusal guards
Analgesia or anxiolysis as a separate procedure except for administration of nitrious
oxide
The agency evaluates a request for dental-related services that are listed as noncovered under the
provisions in WAC 182-501-0160.
Dental-Related Services
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Clients of the Developmental
Disabilities Administration
Clients eligible for enhanced services
Note: Clients of the Developmental Disabilities Administration (DDA) of the Department of
Social and Health Services (DSHS) may be entitled to more frequent services.
These individuals will be identified in ProviderOne as clients of DDA. Individuals not identified
as such are not eligible for the additional services. If you believe that a patient may qualify for
these services, refer the individual or the patient’s guardian to the nearest DDA Field Office.
You may find current contact information for DDA on the Statewide Contacts website.
What additional dental-related services are
covered for clients of the Developmental
Disabilities Administration?
(WAC 182-535-1099)
Subject to coverage limitations, restrictions, and client age requirements identified for a specific
service, the agency pays for the following dental-related services under the following categories
of services that are provided to clients of DDA. This provider guide also applies to clients of
DDA, regardless of age, unless otherwise stated in this section.
Preventive services
Periodic oral evaluations
The agency covers periodic oral evaluations up to three times in a 12-month period.
Dental prophylaxis
The agency covers dental prophylaxis up to three times in a 12-month period (see Periodontic
Services for limitations on periodontal scaling and root planing).
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Topical fluoride treatment
The agency covers topical fluoride varnish, rinse, foam or gel, up to three times within a 12-
month period per client, per provider or clinic.
Sealants
The agency covers sealants:
Only when used on the occlusal surfaces of:
Primary teeth A, B, I, J, K, L, S, and T.
Permanent teeth 2, 3, 4, 5, 12, 13, 14, 15, 18, 19, 20, 21, 28, 29, 30, and 31.
Once per tooth in a two-year period.
Other restorative services
The agency covers the following restorative services:
All recementations of permanent indirect crowns
Prefabricated stainless steel crowns, including stainless steel crowns with resin window,
resin-based composite crowns (direct), prefabricated esthetic coated stainless crowns, and
prefabricated resin crowns for primary anterior teeth once every two years only for
clients 20 years of age and younger without prior authorization
Prefabricated stainless steel crowns, including stainless steel crowns with resin window,
resin-based composite crowns (direct), prefabricated esthetic coated stainless crowns, and
prefabricated resin crowns for primary posterior teeth once every two years only for
clients 20 years of age and younger without prior authorization if one of the following
applies:
Decay involves three or more surfaces for a primary first molar.
Decay involves four or more surfaces for a primary second molar.
The tooth had a pulptomy.
Prefabricated stainless steel crowns, including stainless steel crowns with resin window,
and prefabricated resin crown for permanent posterior teeth excluding teeth 1, 16, 17,
and 32, once every two years without prior authorization for any age.
Dental-Related Services
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Periodontic services
Surgical periodontal services
The agency covers:
Gingivectomy/gingivoplasty (does not include distal wedge procedures on erupting
molars) once every three years. Documentation supporting the medical necessity of the
service must be in the client's record (e.g., drug induced gingival hyperplasia).
Gingivectomy/gingivoplasty (does not include distal wedge procedures on erupting
molars) with periodontal scaling and root planing or periodontal maintenance when the
services are performed:
In a hospital or ambulatory surgical center
For clients under conscious sedation, deep sedation, or general anesthesia.
Nonsurgical periodontal services
The agency covers:
Periodontal scaling and root planing, one time per quadrant in a 12-month period.
Periodontal maintenance (four quadrants) substitutes for an eligible periodontal scaling or
root planing, twice in a 12-month period.
Periodontal maintenance allowed six months after scaling or root planing.
Full-mouth or quadrant debridement allowed once in a 12-month period.
Note: A maximum of two procedures of any combination of prophylaxis,
periodontal scaling and root planing, or periodontal maintenance are allowed in a
12-month period.
Adjunctive general services
The agency covers:
Oral parenteral conscious sedation, deep sedation, or general anesthesia for any dental
services performed in a dental office or clinic. Documentation supporting the medical
necessity must be in the client's record.
Sedation services according to What adjunctive general services are covered?
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Nonemergency dental services
The agency covers nonemergency dental services performed in a hospital or an ambulatory
surgery center for services listed as covered in the following sections in this Washington Apple
Health provider guide:
What preventative services are covered?
What restorative services are covered?
What endodontic services are covered?
What periodontic services are covered?
What oral and maxillofacial surgery services are covered?
Documentation supporting the medical necessity of the service must be included in the client’s
record.
Miscellaneous services-behavior management
The agency covers behavior management provided in dental offices or dental clinics.
Documentation supporting the medical necessity of the service must be included in the client's
record.
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Authorization
Prior authorization (PA) and expedited prior authorization (EPA) numbers do not override the
client's eligibility or program limitations. Not all categories of eligibility receive all services.
General information about authorization
(WAC 182-535-1220 (1) and (5))
The agency uses the determination process for payment described in WAC 182-501-
0165 for covered dental-related services that require prior authorization (PA).
When the agency 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 6 months and only if the client is eligible for covered
services on the date of service.
When do I need to get prior authorization (PA)?
Authorization must take place before the service is provided.
In an acute emergency, the agency may authorize the service after it is provided when the
agency receives justification of medical necessity. This justification must be received by the
agency within seven business days of the emergency service.
When does the agency deny a PA request?
(WAC 182-535-1220 (6))
The agency denies a request for a dental-related service when the requested service:
Is covered by another Washington Apple Health program.
Is covered by an agency or other entity outside the Medicaid agency.
Fails to meet the program criteria, limitations, or restrictions in this Washington Apple
Health provider guide.
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How do I obtain written PA?
(WAC 182-535-1220 (2)-(4))
The agency requires a dental provider who is requesting PA to submit sufficient, objective,
clinical information to establish medical necessity.
Providers must submit the request in writing on a completed General Information for
Authorization form, HCA 13-835. See the agency’s current ProviderOne Billing and
Resource Guide for more information.
The agency may request additional information as follows:
Additional X-rays (radiographs) (the agency returns X-rays only for approved requests
and if accompanied by self-addressed stamped envelope)
Study model, if requested
Photographs
Any other information requested by the agency
Note: The agency may require second opinions and/or consultations before
authorizing any procedure.
Removable dental prosthetics
For nursing facility clients, the PA request must also include a completed copy of the
Denture/Partial Appliance Request for Skilled Nursing Facility Client form, HCA 13-788.
Note: For information on obtaining agency forms, refer to Available Resources.
Where do I send requests for PA?
PA requests must be faxed to the agency at (866) 668-1214 using the General Information for
Authorization form, HCA 13-835.
For information regarding submitting prior authorization requests to the agency, see Requesting
Prior Authorization in the ProviderOne Billing and Resource Guide.
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Without X-rays or photos
For procedures that do not require X-rays, fax the PA request to the agency at:
(866) 668-1214.
With X-rays or photos
In order the scanning & optical character recognition (OCR) functions to work you must pick
one of following options for submitting X-rays or photos to the agency:
Use the FastLook™ and FastAttach™ services provided by National Electronic
Attachment, Inc. (NEA). You may register with NEA by visiting www.nea-fast.com
and entering “FastWDSHS” in the blue promotion code box. Contact NEA at
1-800-782-5150, ext. 2, with any questions.
When this option is chosen, you can fax your request to the agency and indicate the
NEA# in the NEA field on the PA Request Form. There is a cost associated which will
be explained by the NEA services.
Continue to mail your requests to:
Authorization Services Office
PO Box 45535
Olympia, WA 98504-5535
If you choose to mail your requests, the agency requires you to:
1. Place X-rays in a large envelope.
2. Attach the PA request form and any other additional pages to the envelope (i.e. tooth
chart, perio charting etc.)
3. Put the client’s name, ProviderOne ID#, and section the request is for on the envelope.
Note: For orthodontics, write “orthodontics” on the envelope.
4. Place in a larger envelope for mailing. Multiple sets of requests can be mailed together.
5. Mail to the agency.
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What is expedited prior authorization (EPA)?
The expedited prior authorization (EPA) process is designed to eliminate the need for written
requests for prior authorization for selected dental procedure codes.
The agency allows for use of an EPA for selected dental procedure codes. The criteria for use of
an EPA are explained below.
The EPA number must be used when the provider bills the agency.
Upon request, a provider must provide documentation to the agency showing how the
client's condition met the criteria for EPA.
A written request for prior authorization is required when a situation does not meet the
EPA criteria for selected dental procedure codes.
The agency may recoup any payment made to a provider if the provider did not follow
the required EPA process and criteria.
EPA numbers
1. If the client’s medical condition does not meet all of the specified criteria, prior
authorization (PA) must be obtained by submitting a request in writing to the agency (see
Resources Available).
2. It is the vendor’s responsibility to determine whether the client has already been provided
the service allowed with the EPA criteria. If the vendor determines that the client has
already been provided the service, a written prior authorization request must be submitted
to the agency.
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EPA procedure code list
CDT
Code*
Description
EPA #
Criteria
D0150
Comprehensive oral
evaluation – new or
established patient
870001327
Allowed for established patients who have a
documented significant change in health
conditions.
D1515
Space maintainer -
fixed - Bilateral
870001308
Allow to replace an existing unilateral fixed
space maintainer when teeth 3 & 14 or 19 & 30
have erupted
D2335
Resin-based
composite - four or
more surfaces or
involving incisal
angle (anterior)
870001307
Allow for primary anterior teeth
(CDEFGHMNOPQR) when determined
medically necessary by a dental practitioner and
a more appropriate alternative to a crown.
*If a bill for a crown on the same tooth is
received within 6 months the amount paid for
this treatment will be recouped.
Note - In addition to the EPA # on your claim,
you will need to enter a claim note "Pay per
authorization - see EPA information"
D3120
Pulp cap - indirect
(excluding final
restoration)
870001309
Allow for a primary tooth when determined
medically necessary by a dental practitioner and
a less costly alternative to a therapeutic
pulpotomy.
D7971
Excision of
pericoronal gingiva
870001310
Allow when determined to be medically
necessary by a dental practitioner for treatment
of a newly erupting tooth.
* The CDT code and nomenclature above have been obtained from Current Dental Terminology
(including procedure codes, nomenclatures, descriptors and other data contained therein) (CDT). CDT is
copyright © 2013 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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Billing
What are the general billing requirements?
Providers must follow the agency’s ProviderOne Billing and Resource Guide. These billing
requirements include:
What time limits exist for submitting and resubmitting claims and adjustments.
When providers may bill a client.
How to bill for services provided to primary care case management (PCCM) clients.
How to bill for clients eligible for both Medicare and Medicaid.
How to handle third-party liability claims.
What standards to use for record keeping.
Note: If an ICD9 diagnosis code is entered on the dental billing and it is an
invalid diagnosis code, the claim will be denied.
How do facilities bill?
The agency covers medically necessary dental-related services provided to an eligible client in a
hospital-based dental clinic when the services:
Are provided in accordance with Chapter 182-535 WAC.
Are billed on a 2006 ADA or UB 04 Claim Form or appropriate electronic transaction.
The agency pays a hospital for covered dental-related services, including oral and maxillofacial
surgeries, that are provided in the hospital’s operating room when:
The covered dental-related services are medically necessary and provided in accordance
with Chapter 182-535 WAC.
The covered dental-related services are billed on a UB-04 claim form.
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The agency pays an Ambulatory Surgery Center for covered dental-related services, including
oral and maxillofacial surgeries that are provided in the facilities operating room, when:
The covered dental-related services are medically necessary and provided in accordance
with Chapter 182-535 WAC.
The covered dental-related services are billed on a CMS-1500 claim form.
How do I bill for clients eligible for both
Medicare and Medicaid?
Medicare currently does not cover dental procedures. Surgical CPT procedure codes
10000-69999 must be billed to Medicare first. After receiving Medicare’s determination,
submit a claim to the agency. Attach a copy of the Medicare determination.
How do I bill when there is third-party liability?
For dental services, you may elect to bill the agency directly and the agency will recoup from the
third party. If you know the third party carrier, you may choose to bill them directly. The client
may not be billed for copays.
For all medical claims, refer to the agency’s current ProviderOne Billing and Resource Guide.
What are the advance directives requirements?
All Medicare-Medicaid certified hospitals, nursing facilities, home health agencies, personal
care service agencies, hospices, and managed health care organizations are federally
mandated to give all adult clients written information about their rights, under state law, to
make their own health care decisions.
Clients have the right to:
Accept or refuse medical treatment.
Make decisions concerning their own medical care.
Formulate an advance directive, such as a living will or durable power of attorney, for
their health care.
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Fee Schedule &
ADA Claim Form
Where can I find dental fee schedules?
For CDT/dental codes – see the agency’s Dental Fee Schedule.
For dental oral surgery codes, see the agency’s Physician-Related Services Fee Schedule.
Note: Bill the agency your usual and customary charge.
How do I complete the ADA claim form?
Important! Refer to Appendix K of the agency’s current ProviderOne Billing and Resource
Guide for specific instructions on completing the ADA claim form.
