Apple Health (Medicaid): Provider Alert

Orthognathic prior authorization requests

When initial orthodontic prior authorization requests indicate orthognathic surgery may be needed toward the end of the orthodontic treatment, the Health Care Authority (HCA) requires the prior authorization request to include a short letter from an oral surgeon indicating a commitment to treat the client if surgery becomes medically necessary. If the initial orthodontic request does not include the commitment letter, HCA will reject the request with instructions to resubmit the request with a commitment letter.

Six to eight weeks prior to the anticipated orthognathic surgery date, per the orthodontic treatment plan, the oral surgeon who committed to treat the client will evaluate the client to determine if surgery is medically necessary. If the oral surgeon determines that surgery is medically necessary, the surgeon must submit a prior authorization request to HCA that includes documentation explaining the anticipated surgical intervention(s), current facial and intraoral photos, a cephalometric x-ray, procedure codes that will be billed, and the expected date of surgery. HCA will reject the surgical request if it is submitted prior to the six to eight week timeframe. 

Thank you for your continued care and services to our mutual clients. 

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.