Apple Health (Medicaid): Provider Alert

Prior authorization for four or more extractions making a patient edentulous

Previously, the Health Care Authority (HCA) processed authorization requests for extractions and approved them with the expectation that our providers would bill surgical and simple extractions as necessary. However, our Data Analytics and Review Unit found surgical extractions were billed when simple extractions would have been a less costly and equally effective treatment. As a result of these findings, we are reminding you that our dental consultants review these requests for medical necessity and approve or deny according to the criteria listed in WAC 182-501-0165. 

HCA requires you to submit a prior authorization requests for simple and surgical extractions with the appropriate CDT code along with the tooth number(s) on the General Information for Authorization (HCA 13-835) form. If the authorization request for surgical extractions is denied, you may submit a prior authorization request for simple extractions. If you feel a surgical extraction would be more appropriate, resubmit the prior authorization request indicating why surgical extractions are more appropriate. You must include the documented medical justification with the request. 

Note: If you have been approved for simple extractions, but decide during the procedure that a tooth requires surgical extraction, you may request a retroactive authorization by submitting records that indicate the medical justification for performing a surgical extraction instead of a simple extraction.

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.