Apple Health (Medicaid): Provider Alert

This alert is a follow-up message to an alert issued on March 24, 2017. The most recent version of the Orthodontic Information form (dated 5/17) has some minor changes from the last revision (dated 1/17), including an example form on page 4.

As stated in the previous alert, providers must use the updated Orthodontic Information form (HCA 13-666) for orthodontic treatment prior authorization (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.

The updated form is available for download on the agency’s Forms & publications web page and should 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.