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Filing Claims for Orthodontic Treatments

Filing claims for orthodontic treatments can be a real pain if you don't know what you are doing. Insurance providers have specific guidelines for the reimbursement of orthodontic claims as these treatments can span over multiple plan years. This makes processing these claims a complex task that requires some effort. Practices need to follow specific claim submission protocols to ensure that their claims get paid. If any of the information or documentation is incomplete or missing while submitting these claims, it can result in denials.

Dec 19, 2023 3 min read
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Steps Involved in the Submission of an Orthodontic Claim:

Insurance Eligibility and Benefit Verification

The first stage in the process is to determine patient eligibility for orthodontic benefits. For dental insurance verification and coverage, get in touch with the patient or insurance provider, as orthodontic benefits vary greatly between different policies. The various pieces of information that need to be verified include details that are verified for regular dental services, like the name and date of birth of the patient, the name and contact information of the insurance provider, and also the insurance policy number. The practice also needs to get in touch with the insurance provider so as to learn the lifetime maximum, the percentage of the premium that the carrier is responsible for paying, the copayment and deductible, as well as any restrictions like age and dependency status. Keep in mind that all this needs to be carried out before the patient’s appointment.

Coordination of Benefits (COB)

When a patient has dual coverage or is covered by multiple insurance plans, coordination of benefits becomes really crucial. Once the primary and secondary carriers are identified, claims need to be submitted in accordance with the rules that specify the sequence in which the dental practice must bill each health insurance plan.

Claim Submission

While filing a reimbursement claim form that has been filled out completely, a statement outlining the treatment plan and the financial arrangements should be submitted. The documentation must include the estimated length of treatment, the payment plans, and the anticipated insurance payment, if any.

Information That Needs to Be Included While Submitting Orthodontic Claims:

  • The procedure code, together with a description of the appliance used and treatment.
  • The banding date.
  • The anticipated number of months during which the patient will undergo treatment.
  • The total amount you want to be paid for the services.

Points to Be Noted While Reimbursing for Orthodontic Treatments:

  • The treatment expense needs to be related to the coverage duration. Reimbursing an entire orthodontic expense in one year usually violates the IRS requirement that the expense be spent during the coverage period because orthodontic expenses typically span two or more years. The cost of orthodontic treatment will be spread out over the duration of the treatment.
  • The patient should be receiving ongoing orthodontic treatment. Payments made after orthodontic treatment has ended are not eligible for reimbursement.
  • The entire expense of the orthodontic treatment cannot be fully reimbursed at the time of payment.
  • Payments may be made in monthly, quarterly, or annually over the duration of treatment, depending on the insurance provider.
  • If a patient is paying for an orthodontic treatment on a monthly basis, the monthly payments can be reimbursed as they are incurred.
  • Note that if adjustments or extractions are required to complete the orthodontic treatment, they will most likely be covered by the dental insurance. However, in rare instances, they will be billed from the orthodontic benefit.

Here Are Some Tips on Submitting Orthodontic Claims:

  • Diagnostic casts, photographs, or radiographic images need not be sent unless the insurance provider specifically requests them.
  •  Make sure that claims are submitted with accurate, clean, and complete documentation.
  • Never submit orthodontic treatment along with general dentistry treatment on the same claim form.
  • Make sure to note down the start date–the date that braces are placed, appliances are fitted for the teeth, or aligners are delivered. This is a requirement for most insurance provider.
  • If the contract fee is less than the cost of orthodontic treatment, the insurance provider can be contacted to discuss options.
  • It is better to assign benefits to ensure that the insurance payments are received directly by the practice.

While these tips should generally help make the orthodontic claim preparation and submission easier and more streamlined, practices need to remember that each insurance provider could have specific requirements to accept orthodontic claims. Providers like Aetna and Delta Dental have their orthodontic claim submission requirements on their websites. Also consider that nothing can replace the eligibility and verifications process when ensuring that you prepare your claims accurately.  

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