Topic of the month
What is medical necessity and why is it important for Apple Health (Medicaid)?
Medical necessity can be a confusing or new term for oral health teams. Medical necessity or medically necessary care is a foundational principle for health care coverage under Apple Health (Medicaid) as described in WAC 182-501-0050.
WAC 182-500-0070 defines medically necessary as:
"A term for describing requested service which is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent worsening of conditions in the client that endanger life, or cause suffering or pain, or result in an illness or infirmity, or threaten to cause or aggravate a handicap, or cause physical deformity or malfunction. There is no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the client requesting the service. For the purposes of this section, ‘course of treatment’ may include mere observation or, where appropriate, no medical treatment at all.”
The Apple Health dental program uses this definition to evaluate services and prior authorization requests for treatment. In some instances, like treatment of periodontal disease, evidence-based guidelines, radiographs, clinical findings (bone loss, periodontal probing, etc.), and a diagnosis establish medical necessity for the planned and provided treatment.
In other instances, the Apple Health dental program’s billing guide specifies a letter of medical necessity for some services that require prior authorization. General anesthesia is one example of a service that requires a letter of medical necessity. This letter should outline the client’s health history, dental diagnosis, or factors that render the requested service necessary.
The chart record for each client should document medical necessity in the form of a diagnosis (gold standard), finding, or existing condition. There are many ways a provider can do this. Here are a few best practices.
SOAP note
A traditional subjective objective assessment and procedure (SOAP) note can be helpful to ensure this is included in the record. In a group practice setting, templated notes often can support such standard documentation while ensuring individual patient details are still captured and recorded.
Odontogram
An odontogram provides another method for documenting existing dental treatment, current findings, conditions, or diagnoses, and depending on the dental record system, may even include treatment plan.
Diagnostic coding
Diagnostic coding (example: ICD-10), while not required or commonly used in dental, is becoming more widely available through Electronic Health Records systems and is another way to document a diagnosis.
Other documentation
Additional documents in the form of medical consultation reports for an oral health need, a letter of medical necessity, as referenced above, or medical problem list are other examples that may help support documenting of medical necessity for a patient.
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