14.2.3.2 Required DocumentationIn addition to the CSHCN Services Program Prior Authorization Request for Dental or Orthodontia Services form, documentation must accompany the request for prior authorization and must include the date of service the documentation was obtained and a complete orthodontia treatment plan including all procedures required to complete full treatment, such as extractions, orthognathic surgery, upper and lower appliances, monthly adjustments, appliance removal if needed, and special appliances. The CSHCN Services Program may also request the following:
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• The following information must be provided in the case of a transfer of care from one provider to another:
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Properly occluded and anatomically trimmed dental models that demonstrate centric relation when standing on their bases for clients without cleft palate
