Update to orthodontic form and reminder on PA requests

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Apple Health (Medicaid) Provider Alert

Attention Dental Providers:

Effective July 1, 2018, the agency will change the Orthodontic Information (HCA 13-666) form. Part II of the form clarifies the requirement of photographic evidence confirming deep impinging overbites when the lower incisors are destroying the soft tissue of the palate.


When you submit prior authorization requests for comprehensive orthodontic treatment (CDT D8080), the client must be in adolescent dentition, as defined in the description of CDT D8080 and WAC 182-535A-0040(5)(d). If one of the following conditions apply, providers can indicate that a client is in adolescent dentition in Part I of the Orthodontic Information (HCA 13-666) form:

  • A primary tooth/teeth will be extracted once room is made for impacted permanent tooth/teeth during treatment.
  • A primary tooth/teeth is ankylosed and permanent tooth/teeth is missing. 

Also, as a reminder, CDT D8070 Comprehensive orthodontic treatment of the transitional dentition is a noncovered code. If you submit an exception to rule (ETR) request for CDT D8070, you must indicate this in box 30 on the General Information for Authorization (HCA 13-835) form. A letter or chart note is required that demonstrates that the client's clinical condition is so different from the majority, that there is no equally effective, less costly covered service or equipment that meets the client's need (WAC 182-502-0160). 

The forms referenced in this Provider Alert are available for downloading on the agency’s Forms and publications webpage.