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 Washington State Health 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.