Apple Health - Updated Orthodontic Information Form, HCA 13-666
Washington State Health Care Authority sent this bulletin at 01/03/2017 02:29 PM PST
Apple Health (Medicaid): Provider Alert
In order to correctly process prior authorization (PA)
requests for orthodontic treatment, the Health Care Authority (agency) revised
the Orthodontic Information form (HCA
13-666).
Effective
for dates of service on and after April 1, 2017,
providers must use the updated Orthodontic
Information form (HCA 13-666) for orthodontic treatment PA requests. HCA
13-666 must be submitted in addition to the General
Information for Authorization form (HCA 13-835). The agency will reject all
PA requests for orthodontic treatment that are not submitted on the revised
form.
Part II, #3, of the updated form requires the provider
to submit a colored photograph if the client has an overjet greater than 9mm
with incompetent lips, or a reverse overjet greater than 3.5mm with reported
masticatory and speech difficulties.
The updated form is available for download on the
agency’s Forms & publications
web page and can be used immediately.
Please do
not reply directly to this message. If you have feedback
or questions, please visit the HCA
website for contact information.
About
WashingtonStateHealth Care Authority HCA oversees the state’s top
two health care purchasers — Washington Apple Health (Medicaid) and the Public
Employee Benefits Board Program. We work with partners to help ensure
Washingtonians have access to better health and better care at a lower cost. For
more information, visit www.hca.wa.gov.