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The Health Care Authority is issuing a correction to the Dental Providers Newsletter that was published March 27, 2025. We have updated the information about prior authorization services denied for clients age 0 to 20.
HCA's new Dental Program newsletter provides helpful information, answers frequently asked questions, and increases provider understanding of the Apple Health (Medicaid) Dental Program. Please continue to share this newsletter with your colleagues and encourage them to subscribe.
Email the Dental Program with questions or topics you'd like covered in the newsletter.
Sign up for HCA's dental bulletins if you are not yet subscribed.
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Topic of the month: Noncovered dental services for clients age 0 to 20
Understanding all aspects and policies for the Apple Health (Medicaid) program can be challenging. In particular, the authorization processes for noncovered services for both children and adults are areas of confusion and have required frequent clarification for providers.
What is required for Apple Health clients age 0 to 20 when a noncovered service is identified by a provider?
EPSDT is a federally mandated, comprehensive, and preventive pediatric health care benefit. EPSDT requires coverages for all medically necessary health care services regardless of whether such services are covered under the state plan or exceed specific service limits. Each service must be reviewed for clients in this age group.
How do I submit a request for a noncovered service for Apple Health clients age 0 to 20?
A prior authorization should be submitted, including any necessary documentation, and will be reviewed by HCA. Determination of whether a service is medically necessary for an individual is made on a case-by-case basis, taking into account the particular needs of the child. HCA evaluates requests for medical necessity based on the definition in WAC 182-500-0070 and the process in WAC 182-501-0165.
What if the prior authorization for services for clients age 0 to 20 is denied?
If a prior authorization request is denied per process above, the provider and client will both receive a denial notice.This notice also outlines the opportunity for a hearing. At this point, the provider and client/guardian can discuss the following options:
- Proceed with hearing request for the denied service. For more information on this process see Chapter 182-526 WAC.
- Consider possible treatment alternatives, if clinically appropriate.
- Proceed with denied service; client/guardian elects to pay for services.
- The client must sign the Waiver for Noncovered Healthcare Services and agree to payment before the client can be billed.
- Ensure the authorization number and denial notice for the requested service are documented in the form.
- Keep the original agreement in the client’s medical record for 6 years from the date this agreement is signed.
- Give a copy of this completed, signed agreement to the client.
- The dental program will be reviewing the Waiver for Noncovered Healthcare Services form for revision based on recent feedback from providers.
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Change of staff
Pixie Needham, our former Clinical Dental Program Manager, has retired. Jayson Diaz, whom you may know from his work with our team, is now in this role.
Washington State budget shortfall
For information about the Governor's current priorities and budget reduction proposals visit the Office of Financial Management's budget webpage.
Apple Health (Medicaid) 101 webinar
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Date: Thursday, May 22
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Time: 5:30 p.m.
We are offering this virtual webinar in partnership with the Arcora Foundation. The webinar is eligible for continuing education credits. We'll provide a foundational overview of Apple Health, debunk myths that cause confusion for providers, and answer questions. Stay tuned for registration details.
Accurate coding
Ensure proper coding for all procedures and services, including codes that pay the same amount. The Dental Program has noted discrepancies on claims related to radiographs.
Example: D2150 and D2391 are different services that are reimbursed at the same dollar amount. When reviewing radiographs submitted with a prior authorization request, we have observed cases where a tooth billed and reimbursed for D2150 was actually treated with a D2391 service.
Resubscribe to keep receiving updates from HCA
HCA overhauled our provider GovDelivery email lists. Sign in to update your subscriptions to continue receiving updates on relevant topics.
Apple Health Dental Program Facts and Figures report
Arcora Foundation has a data sharing agreement with HCA and annually publishes the Apple Health Dental Program Facts and Figures report.
View the report to understand the Dental Program, including investments, utilization metrics, and opportunities.
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