CSHCN Services Program 2010 > Dental > Benefits, Limitations, and Authorization Requirements

14.2.3.2 Required Documentation

To obtain prior authorization, the provider must submit the CSHCN Services Program Prior Authorization Request for Dental or Orthodontia Services form and a complete orthodontia treatment plan including all procedures required to complete full treatment, such as:

•Extractions.

•Orthognatic surgery.

•Upper and lower appliances.

•Monthly adjustments, appliance removal (if needed).

•Special appliances.

The request must include the date of service that the documentation was obtained.

The CSHCN Services Program may also request the following:

•For clients without cleft palate, properly occluded and anatomically trimmed dental models that demonstrate centric relation when standing on their bases

•A cephalometric radiograph with tracing

•Facial photographs

•A full series of radiographs or a panoramic radiograph

The following information must be provided in the case of a transfer of care from one provider to another:

•A request for prior authorization as outlined above

•Explanation of why the client left the previous provider

•Explanation of the client's treatment status