Title
Approval of Case #26-4 Dental
Report
Issue:
Whether to approve payment in the amount of $3,374.00 for dental services.
Staff Contact:
Debbi Hufana, HR Analyst, Human Resources, 360.753.8149
Background:
LEOFF 1 member is requesting approval for dental services for a root canal and crown in the amount of $3,374.00. This request is in partial compliance with the approval process. It includes the Application for Payment of Services as well as a treatment plan but does not include the bottom portion of the form being completed by the dentist or a letter in lieu of the completed form. I contacted the dentist office to have the provider portion completed however the office is closed until April 13, 2026. The member was informed this would be presented but additional documentation from the provider might be requested prior to approval or denial of request.
Attachments:
Application for payment of services and treatment plan
Reference:
Section III Procedures to Receive Benefits