Orthodontic Medical Necessity Requirements for PA CHIP Program

To comply with Pennsylvania CHIP dental program guidelines, United Concordia recommends that orthodontists complete the Orthodontic Decision Checklist (ODC) PDF icon to determine medical necessity for members enrolled in this program.  Completing the ODC will help to ensure unnecessary treatment is not performed before the final medical necessity determination is made by United Concordia.

If you indicate a “yes” response to one or more of questions 2–8, we ask that you submit the following to United Concordia for a final medical necessity determination:

  1. All anticipated treatment phases with a total case fee
  2. Panorex X-ray*
  3. Study Models*
  4. Salzmann Index PDF icon (reflecting a score of 25 or higher)

If one of the questions 2–8 on the ODC is not a “yes” response, most likely the orthodontic case will not meet medical necessity. As a reminder, all orthodontic services for CHIP members require prior approval. Should you have any questions, please contact Dental Customer Service at 1-800-332-0366.

* Study models and X-rays will automatically be returned to your office within 45 days.