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Apple Health Oral Health Advisory Workgroup
The Health Care Authority (HCA) Dental Program began the Apple Health (Medicaid) Oral Health Advisory Workgroup in January 2025. The workgroup brings together a diverse group of stakeholders, including significant representation from Apple Health dental providers across specialties, as well as cross agency representation from Department of Social and Health Services (DSHS) Developmental Disabilities Community Services (DDCS), Department of Health (DOH), and Fostering Well-Being (FWB).
The workgroup provides valuable expert input to help improve the Apple Health Dental Program and offers feedback on the Apple Health dental benefit, policies, and processes.
Highlights from the first year of the workgroup:
- Built connections between members and established norms for workgroup sessions.
- Deepened understanding of Medicaid programs by examining Washington and other states using data and tools such as and the Carequest Medicaid Adult Dental Coverage Check and the Arcora Foundation's Medicaid Facts & Figures.
- Developed and prioritized future topics, such as dental access for people with disabilities, and consideration of new services and codes.
- Identified need and opportunities to improve prior authorization processes, for example:
- Crown build-up and post-and-core services no longer require prior authorization for clients age 20 and younger.
- Designed new prior authorization processes and forms for dental prostheses, including the newly updated denture/partial appliance request for skilled nursing facility client form (HCA 13-788).
- Provided input on the impact of Engrossed Substitute Senate Bill 5167, a bill which includes Apple Health dental rate reductions for children and adults.
- Identified key services within the benefit to maintain and prioritize for improvement when resources are available.
- Identified opportunities for future benefit improvement by category (e.g. preventive, restorative, oral surgery) using available best practice guidelines and evidence.
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Denture identification requirement
- Apple Health providers fabricating dentures for clients are required to include identification in the denture.
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WAC 246-812-360 and RCW 18.32.695 require that complete upper and lower dentures and removable dental prostheses, fabricated by licensed dentists, denturists, or pursuant to their work order, be marked with the patient's name. This marking must be done during fabrication, be permanent, legible, and cosmetically acceptable.
Immediate dentures: non-covered under Apple Health Dental
- The Apple Health Dental Program has seen an increase in client complaints related to dentures that were billed as complete dentures. Records show they were fabricated and delivered as an immediate denture. Providers may be subject to audit and/or recoupment of payment for this practice.
- The fabrication of a Maxillary or Mandibular denture prior to the extraction of the client’s teeth and/or the delivery of the denture at or near the time of extraction is not allowed. The fabrication of a denture prior to extractions is an immediate denture, regardless of whether delivery is the day of or a few days after.
- Providers cannot fabricate an immediate denture and bill it as a complete denture. An immediate denture is a non-covered service, per WAC 182-535-1100.
- The Academy of Prosthodontics defines an immediate denture as any fixed or removable dental prosthesis fabricated for placement immediately following the removal of natural teeth.
Updated form 13-788 denture/partial appliance request for skilled nursing facility client
- The Apple Health Dental Program will allow providers to continue using the previous version of the form until April 1, 2026.
- For prior authorization requests submitted on or after April 1, 2026, HCA will require providers to use the current version.
- After March 31, 2026, prior authorization requests using previous versions of the form will be rejected.
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