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Professional Services -

Dental Services

Dental providers licensed in the state in which they practice may be paid for performing dental services (WAC 296-20-110 and WAC 296-23-160).

This policy pertains to bills submitted for dental services.

PRE-EXISTING CONDITIONS

Pre-existing conditions are not payable unless medically justified as related to the injury. Preauthorization is required for treatment.

Any dental work needed due to underlying conditions unrelated to the industrial injury is the responsibility of the worker (WAC 296-20-110). It is the responsibility of the dentist to advise the worker accordingly. Please advise the worker if there are underlying conditions that will not be covered.

Periodontal disease is an underlying condition that is not covered because it is not related to industrial injuries.
To avoid delays in treatment, please exclude information regarding treatment that is not directly related to the injury.

WHO CAN BILL

Dental providers including:

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

BILLING RULES

Provider Number

You must have an L&I provider account number to treat and be paid for services provided to injured workers (WAC 296-20-015). You can find more information about becoming an L&I provider at http://www.Lni.wa.gov/ClaimsIns/Providers/Becoming/default.asp

For self-insured workers‘ compensation claims contact the insurer directly for provider account number requirements. For assistance in locating self-insurers go to:
http://www.Lni.wa.gov/ClaimsIns/Insurance/SelfInsure/EmpList/Default.asp

BILLING INSTRUCTIONS

Billing Forms

To submit a billing for State Fund claims, dentists should use L&I‘s Statement for Miscellaneous Services form. To submit a billing for Crime Victims Compensation (CVC) claims, dentists should use CVC‘s Statement for Crime Victims miscellaneous Services. Forms can be found at http://www.Lni.wa.gov/FormPub/BySubject.asp.

Failure to use L&I‘s most recent billing form may delay payment.

Complete the billing form itemizing the service rendered, including the code, materials used and the injured tooth number(s). When using Current Dental Terminology (CDT®) codes, please include the "D" in front of the code billed to avoid delays in claim/bill processing. Bills must be submitted within one year from the date the service is rendered (WAC 296-20-125).

AUTHORIZATION AND TREATMENT PLAN REQUIREMENTS

Contact the following for procedures requiring prior authorization:

• L&I claim manager for state workers‘ compensation claims and CVC claims
• 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.

http://www.Lni.wa.gov/ClaimsIns/Insurance/SelfInsure/EmpList/Default.asp

To obtain authorization for a treatment plan the following are required:

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

Please include:

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

Do not use a billing form to submit your treatment plan.

TREATMENT PLAN SUBMISSION

Claim services requiring prior authorization require a treatment plan. The dentist should outline the extent of the dental injury and the treatment plan (WAC 296-20-110).

The treatment plan and/or alternative treatment plan must be completed and submitted before authorization can be granted. 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 Xrays may be requested.

PRIOR AUTHORIZATION REVIEW

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, consultation by another dentist may be requested by the claim manager to support authorization for procedures.

To avoid delays in authorization of treatment, include the following in your plan:

• Worker‘s full name,
• Claim number,
• Provider name, address and telephone number

State the condition of the mouth and involved teeth including:

• Missing teeth, existing caries and restorations.
• Condition of involved teeth prior to the injury (caries, periodontal status).

Mail State Fund treatment plans to:

Department of Labor & Industries
PO Box 44291
Olympia, Washington 98504-4291

Mail CVC claim treatment plans to:

Department of Labor & Industries
PO Box 44520
Olympia, Washington 98504-4520

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

(360) 902-4292
(360) 902-4565
(360) 902-4566
(360) 902-4567
(360) 902-5230
(360) 902-6100
(360) 902-6252
(360) 902-6460

SELF-INSURERS TREATMENT PLAN PROCEDURES

For self-insured claims, contact the self-insurer directly for treatment plan submission procedures.
http://www.Lni.wa.gov/ClaimsIns/Insurance/SelfInsure/EmpList/Default.asp

DOCUMENTATION AND RECORDKEEPING REQUIREMENTS

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 (WAC 296-20-010). Legible copies of office notes are required for all initial and follow-up visits (WAC 296-20-06101).

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. You initiate the State Fund claim or CVC claim for your patient when you send an accident report to L&I.

The State Fund Report of Industrial Injury or Occupational Disease (Accident Report) (ROA) form can be ordered at:
http://www.Lni.wa.gov/FormPub/Detail.asp?DocID=1599 or call 800-LISTENS or 1-360-902-4300.

To request a supply of the Provider‘s Initial Report (PIR) form used for worker‘s of self-insured employers, call 1-360-902-6898.

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.
• Restrictions to recovery,
• 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 (Subjective, Objective, Assessment, Plan and progress) format. Information on the format can be found in the Charting Format section, page 18 of this document.

L&I’S REVIEW OF DENTAL SERVICES

L&I or its designee may perform periodic independent evaluations of dental services provided to workers. Evaluations may include, but are not limited to, review of the injured worker‘s dental records.