What is an exception to the rule (ETR)? 

A dental client or the client's provider may request the Health Care Authority (HCA) pay for a noncovered health care service. This type of decision is called an exception to the rule (ETR). Unlike pediatric clients, the ETR process can be waived by the adult client age 21 and older.

For HCA to consider the ETR request: 

• The provider must demonstrate that the client's condition is so different from the majority and that there is no equally effective, less costly covered service or equipment that meets the client's needs. 
• The provider must certify that medical treatment or services covered under Apple Health (Medicaid) with accepted standards of medical practice and indicated as appropriate for the treatment of the illness or condition, have been found to be: 
  • Medically ineffective in the treatment of the client's condition; or  
  • Inappropriate for that specific client. 
• WAC 182-501-0160 outlines that any requested item or service must:    
  • Fall within accepted standards and precepts of good medical practice; 
  • Represent cost-effective use of public funds; and 
  • Be submitted to the agency or its designee in writing within 90 days of the date of the written notification denying authorization for the noncovered service. 

All requests must also establish medical necessity, as defined in WAC 182-500-0070. 

How do I submit an ETR request for an adult (21+)?  

If you identify a noncovered health care service while providing care to an Apple Health client, follow these steps:

• Submit prior authorization request for the noncovered service.
• The request will be denied for noncovered services. The receipt of a denial notice will inform the client that they may do one of the following: 
  • Request a fair hearing as outlined in Chapter 182-526 Washington Administrative code (WAC), or  
  • Ask their provider to initiate the ETR process, or 
  • Waive the ETR process and proceed with payment for service(s).
• If the client decides to initiate the ETR process, submit the client’s request, including all necessary documentation, and indicate in the comments box that you are requesting an ETR. The ETR must be submitted after a denial for the noncovered service has been received and prior to treatment. 
• The requested service will now be reviewed for medical necessity per WAC 182-501-0160.  

What if the client wants to waive the ETR process? 

If the client decides to waive the ETR process, and proceed with the original treatment plan, they may elect to do so.

• The client must sign the Agreement to pay for healthcare services form and agree to payment before the client can be billed.   
• Fill out all the appropriate boxes. 
  • For “Reason why the client is agreeing to be billed" select Noncovered service, ETR waived.
• Give a copy of this completed, signed agreement to the client. Keep the original agreement in the client’s medical record for 6 years from the date this agreement is signed. 

What if the ETR is denied? 

A client does not have a right to a fair hearing on ETR decisions. If the client elects to proceed with the original treatment plan:

• The client must sign the Agreement to pay for healthcare services form and agree to payment before the client can be billed.
• Fill out appropriate boxes.
  • For “Reason why the client is agreeing to be billed” select Noncovered service, ETR denied.
• Give a copy of this completed, signed agreement to the client. Keep the original agreement in the client’s medical record for 6 years from the date this agreement is signed.