Please read the following message from the HCA: 

The Health Care Authority (HCA) is requiring a new form for orthodontic providers. The form must be submitted to HCA whenever orthodontic treatment has been discontinued prior to completion of treatment.

The Orthodontic Discontinuation of Service (13-0039) form can be found on the agency’s Forms and Publications page.

Providers will submit the notification form using the barcode document submission cover sheet for general prior authorization requests using the prior authorization number from the original approval. The barcode document submission cover sheet can be found on the agency’s prior authorization webpage under Step 4: How to submit a PA request.