HCA: Apple Provider Alert
Attention Medicaid Providers: The Washington State Health Care Authority (HCA) recently published updates effective July 1, 2024, to the Access to Baby and Child Dentistry/Mouth Matters Guide (ABCD), Dental-Related Services Program Billing Guide and Orthodontic Services Billing Guide.
All the changes that have been made are listed at the beginning of the billing guides under the “What has changed?” section.
The changes to the ABCD Guide include updates to CPT® code 99499- Periodic oral evaluation to better align with coverage and well-child checks. The limitation criteria for this code has changed from “one time every 6 months” to “allowed two times within a 12-month period, per provider”.
Changes to the Dental-Related Services Program Billing Guide include, but are not limited to:
- Endodontic Treatment (Root Canal): Endodontic treatment on permanent teeth (CDT code D3320) has been updated to clarify that root canals are covered on primary molars if there is no succedaneous permanent molar. Prior authorization is required.
- Nonsurgical Periodontal Services: Updated terminology by removing outdated reference to "subgingival calculus" in procedure description.
- Resin Partial Dentures: Language added to align with Washington Administrative Code (WAC)182-535-1090: "There is a three-year prognosis for retention of the remaining teeth."
- Coronectomy: For clarity and ease of use, coronectomy coverage has been updated to include tooth designations indicating teeth #1, #16, #17 and #32 are covered. Additionally, prior authorization is no longer required.
- Surgical Excision of Pericoronal Gingiva: Added clarifying language “The Health Care Authority covers excision of pericoronal gingiva for teeth #1, 16, 17, and 32. Excision of pericoronal gingiva is not allowed on the same day as extraction of the same tooth and cannot be billed with D7280 and D7283.”
- Other Surgical Procedures: Added clarification: “Surgical access of an unerupted permanent tooth and placement of a device to facilitate eruption of impacted permanent tooth cannot be billed with an excision of pericoronal gingiva on the same tooth, same date of service.”
- Oral Surgeon Commitment Letter Requirements: Language requiring a commitment letter has been removed to reduce the administrative burden for providers and because the Health Care Authority (HCA) may not require these letters from non-Medicaid providers. This update is also reflected in changes to the pre-authorization requirements and EPA billing criteria.
- Additional Coverage: CDT® code D8070 – Comprehensive orthodontic treatment of the transitional dentition has been added as a covered service. Additionally, CDT® code D8670 Comprehensive orthodontic treatment of the transitional dentition has been updated as a covered service to accompany D8070.
- Medical Justification: Added clarification requiring clear photographs for tissue destruction claims.
- Billing with EPA Number: Added note stating "Using an EPA when not indicated is subject to recoupment" for clarification on use of EPA number and billing.
