Orthodontic treatment – changes to payment methodology, eff 7/1/2019

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Apple Health (Medicaid) Provider Alert

Effective for dates of services on and after July 1, 2019, the Health Care Authority (HCA) is changing the payment methodology for orthodontic treatment. HCA is also changing policy regarding discontinued treatment.

What is changing?

Providers can now bill more frequently (a minimum of every 6 weeks vs. the current 12 weeks).

Providers will be approved for a maximum of 14 units of CDT code D8670 (periodic orthodontic treatment visit) over a 24 to 30-month period for comprehensive orthodontic treatment, and a maximum of 6 units over a 12-month period for limited orthodontic treatment.

CDT code D8670 for periodic orthodontic treatment visits:

  • Use for visits subsequent to the initial appliance placement when the placement date and the date of service are different. Prior authorization is required.
  • Bill in 6-week intervals
  • For limited orthodontic treatment, payment is for a maximum of 6 units.
  • For comprehensive orthodontic treatment, payment is for a maximum of 14 units.

CDT code D8080 for comprehensive treatment:

  • Payment is for initial placement and now includes active treatment for the first 3 months, replacement of brackets and lost or broken orthodontic appliances, appliance removal and initial retainers.
  • Prior authorization is required.

This change is intended to allow the provider more flexibility in the frequency they see clients and the freedom to complete treatment prior to 30 months if treatment goals have been met.

Orthodontic treatment must meet industry standards and correct the medical issue. If treatment is discontinued prior to completion, or treatment objectives are not achieved, the provider must now notify authorization services at 1-800-562-3022 ext. 15468.

HCA will update the Orthodontic-Related Services Billing Guide for July 1, 2019, to reflect these changes.