Prior Authorization

Cranial Remolding Orthosis

All requests for Cranial Remolding Orthosis (CRO) must be medically necessary and require prior authorization.

• Criteria for Cranial Remolding

Documentation Requirements for Prior Authorization Requests:

• Prescription
• Medical Records – including diagnosis, history of treatment, assessment of severity and any other documentation supporting the request.
• Prior Authorization Request Form

Submit completed form to:

• Department of Social Services
  Division of Medical Services
  EPSDT Coordinator
  700 Governors Drive
  Pierre, SD 57501
  
• Phone: 605-773-3495
  
• Fax: 605-773-5246