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182-535A-0040  <<  182-535A-0050 >>   182-535A-0060

PDFWAC 182-535A-0050

Orthodontic treatment and orthodontic-related services—Authorization and prior authorization.

(1) When the medicaid agency authorizes an interceptive orthodontic treatment, limited orthodontic treatment, full orthodontic treatment, or orthodontic-related services for a client, including a client eligible for services under the EPSDT program, that authorization indicates only that the specific service is medically necessary; authorization is not a guarantee of payment. The client must be eligible for the covered service at the time the service is provided.
(2) For orthodontic treatment of a client with cleft lip, cleft palate, or other craniofacial anomaly, prior authorization is not required if the client is being treated by an agency-recognized craniofacial team, or an orthodontic specialist who has been approved by the agency to treat cleft lip, cleft palate, or other craniofacial anomalies.
(3) Subject to the conditions and limitations of this section and other applicable WAC, the agency requires prior authorization for orthodontic treatment and/or orthodontic-related services for other dental malocclusions that are not listed in WAC 182-535A-0040(1).
[Statutory Authority: RCW 41.05.021 and 2013 2nd sp.s. c 4 § 213. WSR 14-08-032, § 182-535A-0050, filed 3/25/14, effective 4/30/14. WSR 11-14-075, recodified as § 182-535A-0050, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 08-17-009, § 388-535A-0050, filed 8/7/08, effective 9/7/08. Statutory Authority: RCW 74.08.090, 74.09.520 and 74.09.035, 74.09.500. WSR 05-01-064, § 388-535A-0050, filed 12/8/04, effective 1/8/05. Statutory Authority: RCW 74.08.090, 74.09.035, 74.09.520, 74.09.500, 42 U.S.C. 1396d(a), C.F.R. 440.100 and 225. WSR 02-01-050, § 388-535A-0050, filed 12/11/01, effective 1/11/02.]
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