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Chapter 8: Dental Services


Billing & Payment Policies for Healthcare Services provided to Injured Workers and Crime Victims



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Effective July 1, 2014

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Payment policy:
All dental services

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Payment policy: All dental services

Note: This policy pertains to bills submitted for dental services.

Prior authorization

Contact the following for procedures requiring prior authorization:

  • L&I claim manager for state workers‘ compensation claims and Crime Victims Compensation (CVC) claims, or
  • Self-insured employer or their third party administrator.

Only claim managers can authorize dental services for State Fund workers‘ compensation claims and CVC claims.

For self-insured workers‘ compensation claims, contact the insurer directly for prior authorization procedure details.

Link: For a list of self-insured employers’ contact information, see: www.Lni.wa.gov/ClaimsIns/Insurance/SelfInsure/EmpList/Default.asp .

Prior authorization review of treatment plan

Claim services requiring prior authorization require a treatment plan. Before authorization can be granted, the treatment plan and/or alternative treatment plan must be completed and submitted.  If other providers are performing services, it will also be necessary for them to submit treatment plans. A 6-point per tooth periodontal chart and/or X-rays may be requested.

Note: See “Treatment plan requirements” later in this section.

The claim manager will review the treatment plan and the relation to the industrial injury and make a final determination for all services relating to:

  • Restorative,
  • Endodontic,
  • Prosthodontic,
  • Prosthetic,
  • Implant,
  • Orthodontics,
  • Surgery, and
  • Anesthesia procedures.

In cases presenting complication, controversy or diagnostic/therapeutic problems, the claim manager may request consultation by another dentist to support authorization for procedures.

Who must perform these services to qualify for payment

Dental providers licensed in the state in which they practice may be paid for performing dental services, including:

  • Dentists,
  • Oral and Maxillofacial surgeons,
  • Orthodontists,
  • Denturists,
  • Hospitals, and
  • Dental clinics.

Dentists must be enrolled in the provider network in order to treat injured workers beyond the initial visit.

Note: Also see information about the Medical Provider Network in the “General information: Becoming a provider” section of the Information for all Providers chapter. Network requirements don’t apply to Crime Victim services.

Links: You can find more information about dental services in WAC 296-20-110 , WAC 296-23-160 , and WAC 296-20-015 , and about becoming an L&I provider at www.Lni.wa.gov/ClaimsIns/Providers/Becoming/default.asp.

For self-insured workers' compensation claims contact the insurer directly for provider account number requirements.

Link: For a list of self-insured employers' contact information, see www.Lni.wa.gov/ClaimsIns/Insurance/SelfInsure/EmpList/Default.asp .

Services that aren’t covered

Pre-existing conditions

Pre-existing conditions aren't payable unless medically justified as related to the injury.

Preauthorization is required for treatment.

Underlying conditions

Any dental work needed due to underlying conditions unrelated to the industrial injury is the responsibility of the worker. It is the responsibility of the dentist to advise the worker accordingly. Please advise the worker if there are underlying conditions that won’t be covered.

Periodontal disease

Periodontal disease is an underlying condition that isn‘t covered because it isn‘t related to industrial injuries.
Link: For more information, see WAC 296-20-110 .

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Requirements for billing

Bills must be submitted within one year from the date the service is rendered.

Link: For more information, see WAC 296-20-125 .

To bill:

  • All workers‘ compensation dental claims should be billed using the ADA American Dental Association Dental Claim Form (© 2012 American Dental Association J430D), or L&I‘s Statement for Miscellaneous Services form (F245-072-000).
  • Crime Victims Compensation (CVC) claims, dentists should use the ADA American Dental Association Dental Claim Form (© 2012 American Dental Association J430D), or CVC‘s Statement for Crime Victims Miscellaneous Services form (F800-076-000).

Note: Failure to use the most recent billing form may delay payment.

Complete the billing form itemizing the service rendered, including the:

  • Full billing code,
  • Materials used, and
  • Injured tooth number(s).

Note: When using Current Dental Terminology (CDT®) codes, please include the “D” in front of the code billed to avoid delays in claim/bill processing.

Link: The HCPCS fee schedule, which includes the dental billing codes, is available at feeschedules.Lni.wa.gov.

Treatment plan requirements

Before authorization can be granted, the treatment plan and/or alternative treatment plan must be completed and submitted. If other providers are performing services, it will also be necessary for them to submit treatment plans. A 6-point per tooth periodontal chart and/or X-rays may be requested.

The dentist should outline the extent of the dental injury and the treatment plan. To obtain authorization for a treatment plan, all of the following are required:

  • Causal relationship of injury to condition of the mouth and teeth, and
  • Extent of injury, and
  • Alternate treatment plan, and
  • Time frame for completion, and
  • Medical history and risk level for success.

Please include:

  • Procedure code, and
  • Tooth number, and
  • Tooth surface, and
  • Charge amount.

Notes: To avoid delays in treatment, please exclude information regarding treatment that isn‘t directly related to the injury. The ADA American Dental Association Dental Claim form (© 2012 American Dental Association J430D) may be attached to treatment plan. Select “Request for Predetermination/Preauthorization” in section 1.

In addition, to avoid delays in authorization of treatment, include the following in your plan:

  • Worker's full name, and
  • Claim number, and
  • Provider name, address and telephone number, and
  • State the condition of the mouth and involved teeth including:
    • Missing teeth, existing caries and restorations, and
    • Condition of involved teeth prior to the injury (caries, periodontal status).

Link: For more information, see WAC 296-20-110 .

Where to submit a treatment plan

State Fund treatment plans (not billing info) may be:

  • Faxed to: 360-902-4567, or
  • Mail State Fund treatment plans to:
    Department of Labor & Industries
    PO Box 44291
    Olympia, Washington 98504-4291

Crime Victims Compensation (CVC) treatment plans (not billing info) may be:

  • Faxed to: 360-902-5333, or
  • Mail CVC treatment plans to:
    Department of Labor & Industries
    PO Box 44520
    Olympia, Washington 98504-4520

Mail self-insured treatment plans to the SIE/TPA.

Link: For a list of self-insured employers’ contact information, see www.Lni.wa.gov/ClaimsIns/Insurance/SelfInsure/EmpList/.

Documentation and recordkeeping requirements

Acceptance of a claim

If you diagnose a worker for an occupational injury or disease associated with a dental condition, you are responsible for reporting this to the insurer. To initiate the State Fund claim or CVC claim for your patient, send L&I a Report of Industrial Injury or Occupational Disease form (F242-130-000) (also known as the “Accident Report” or “ROA”).

Links: You can order copies of the ROA (F242-130-000 ) at www.Lni.wa.gov/FormPublications/Ordering.asp?OrderType=MostForms or by calling 1-800-LISTENS or 1-360-902-4300.

To request a supply of the Provider’s Initial Report (PIR) form used for workers of self-insured employers, go to www.Lni.wa.gov/FormPub/Detail.asp?DocID=2467 , or call 1-360-902-6898.

Chart notes

You must submit legible chart notes and reports for all of your services. This documentation must verify the level, type and extent of service. Legible copies of office notes are required for all initial and follow-up visits.

Links: For more information, see WAC 296-20-010 and WAC 296-20-06101 .

Attending provider

If dental treatment is the only treatment the injured worker requires and you are directing the care, you will be the attending provider (AP).

Your responsibility as the AP includes documenting employment issues in the injured worker‘s chart notes, including:

  • A record of the worker‘s physical and medical ability to work, and
  • Information regarding any rehabilitation that the worker may need to undergo, and
  • Restrictions to recovery, and
  • Any temporary or permanent physical limitations, and
  • Any unrelated condition(s) that may delay recovery must also be documented.

For ongoing treatment, use the standard SOAP-ER (Subjective, Objective, Assessment, Plan and progress, Employment issues, Restrictions to recovery) format.

Link: Information on the format can be found in the “Charting format” section of the Information for All Providers chapter.

Additional information: L&I’s periodic review of dental services

L&I or its designee may perform periodic independent evaluations of dental services provided to workers. Evaluations may include, but aren‘t limited to, review of the injured worker‘s dental records.

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If you’re looking for more information about… Then go here:
Administrative rules Medical Aid Washington Administrative Code (WAC) 296-20-110:
http://app.leg.wa.gov/wac/default.aspx?cite=296-20-110
WAC 296-20-015:
http://app.leg.wa.gov/wac/default.aspx?cite=296-20-015
WAC 296-20-125:
http://app.leg.wa.gov/wac/default.aspx?cite=296-20-125
WAC 296-20-06101:
http://app.leg.wa.gov/wac/default.aspx?cite=296-20-06101
Administrative rules dental services, general information and instructions WAC 296-23-160:
http://app.leg.wa.gov/wac/default.aspx?cite=296-23-160
Attending Doctor’s Handbook www.Lni.wa.gov/FormPub/Detail.asp?DocID=1669
Becoming an L&I provider L&I’s website:
www.Lni.wa.gov/ClaimsIns/Providers/Becoming/
Billing instructions and forms Chapter 2:
Information for All Providers
Charting format (“SOAP-ER”) instructions Chapter 2:
Information for All Providers
Fee schedules for all healthcare professional services (including dental) L&I’s website:
http://feeschedules.Lni.wa.gov
Payment policies for diagnostic X-ray services Chapter 26:
Radiology Services
Provider’s Initial Report (PIR) form for all State Fund and crime victims claims L&I’s website:
www.Lni.wa.gov/FormPub/Detail.asp?DocID=2467
Report of Accident (ROA) form for all State Fund and crime victims claims L&I’s website:
www.Lni.wa.gov/FormPub/Detail.asp?DocID=1599
Statement for Crime Victims Miscellaneous Services form for all crime victims claims L&I’s website:
www.Lni.wa.gov/FormPub/Detail.asp?DocID=1976
Statement for Miscellaneous Services form for all worker’s compensation claims L&I’s website:
www.Lni.wa.gov/FormPub/Detail.asp?DocID=1627

Need more help?  Call L&I’s Provider Hotline at 1-800-848-0811.


CDT® codes and descriptions only are © 2012 American Dental Association

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