Unlocking Orthodontic Insurance Billing: A Comprehensive Guide For Practitioners

Orthodontic treatments can be very expensive, with the average cost of braces and orthodontic treatment in the United States ranging from $3,000 to $10,000. Orthodontic insurance can help to save you money and bring down the cost of braces, but it's important to note that not all dental insurance covers orthodontic treatment. Even if your insurance covers orthodontic treatment, there may be a lifetime maximum amount that they will pay towards it. Before starting any treatment, it's crucial to understand what your insurance plan covers and what your out-of-pocket costs may be. This involves reviewing your dental insurance policy, checking for any age restrictions, waiting periods, lifetime maximums, and other limitations.

Confirm orthodontic coverage

Confirming orthodontic coverage is an important step before starting any treatment, as it can help you avoid unexpected costs and ensure you're maximising your insurance benefits. Here are some detailed steps to confirm orthodontic coverage:

• Review your dental plan materials: Carefully read through your dental plan documents to understand the covered and non-covered services. Look for specific mentions of orthodontic treatments such as braces, Invisalign, or other appliances. Some plans may have separate sections outlining orthodontic benefits and their conditions.
• Understand the type of insurance: Different types of insurance plans offer varying levels of orthodontic coverage. Employer-sponsored and private dental insurance plans often provide some coverage for orthodontic treatment. Medicaid, for instance, typically covers orthodontics for individuals under 21. On the other hand, health insurance rarely includes dental coverage, and even dental insurance may not always cover orthodontics.
• Check for age restrictions: Many insurance plans have age restrictions for orthodontic coverage, typically limiting benefits to beneficiaries under 18 or 21. However, some plans do provide coverage for adult orthodontics, so be sure to confirm any age limitations.
• Look for coverage limits and maximums: Dental plans may impose maximum limits on the amount you can spend on orthodontic services annually or over your lifetime. These limits may vary depending on the type of treatment and your age. Additionally, some plans have waiting periods, requiring you to be enrolled for a certain period before orthodontic coverage applies.
• In-network vs Out-of-network providers: Insurance companies usually have a network of in-network providers with whom they have negotiated discounted rates. Using an in-network orthodontist will generally result in lower out-of-pocket costs for you. However, if you prefer an out-of-network provider, be sure to check your plan's coverage for out-of-network care, as this can vary significantly between plans.
• Contact your insurance provider: If you're still unsure about your orthodontic coverage, don't hesitate to reach out to your insurance company. They can provide detailed information about your plan's benefits, including any age restrictions, lifetime maximums, waiting periods, and out-of-pocket expenses.
• Consult your orthodontist's office: Your orthodontist's administrative staff should also be able to help you understand your insurance coverage and expected out-of-pocket costs. They can work with you to navigate the complexities of insurance plans and ensure you receive the benefits you're entitled to.

By following these steps, you can confidently confirm your orthodontic coverage and make informed decisions about your treatment options and financial obligations.

Review the plan's network

When it comes to billing insurance for orthodontics, reviewing the plan's network is crucial. Here are some detailed paragraphs to guide you through this process:

Most dental insurance plans have a network of approved dental providers and orthodontists. It is essential to verify whether the orthodontist you want to see is part of your plan's network. Staying within the network will help you save money. Contact your insurance provider to get a list of in-network orthodontists, or check their website. You can also call your desired orthodontist's office to confirm if they are in-network with your plan.

In-network orthodontists have a contract with your insurance company to provide services at a reduced rate, which can significantly lower your out-of-pocket expenses. Using an in-network orthodontist is usually more cost-effective than going out-of-network. Remember that insurance plans vary, so always check with your insurance provider to understand your specific coverage.

If you have a Preferred Provider Organization (PPO) plan, you may have some level of coverage for out-of-network orthodontists. However, your out-of-pocket costs will likely be higher compared to staying in-network. Out-of-network orthodontists might charge more than what your insurance company is willing to pay, leaving you responsible for the difference.

On the other hand, if you have a Dental Health Maintenance Organization (DHMO) plan, out-of-network care is typically not covered unless it's a genuine emergency. In such cases, you will likely be responsible for the entire treatment cost. Therefore, always check with your insurance company to understand your coverage for out-of-network care.

When reviewing the plan's network, it is also essential to consider any age restrictions. Many insurance plans offer orthodontic coverage only for beneficiaries under a certain age, usually 18 or 21. However, some plans do provide coverage for adult orthodontics, so be sure to check with your insurance provider.

Additionally, when reviewing the plan's network, consider any waiting periods. Some insurance policies require you to be enrolled in the plan for a specific period before you can claim orthodontic benefits. Make sure you understand any waiting periods to avoid unexpected costs.

Finally, when reviewing the plan's network, consider the coverage amount. Insurance plans that cover orthodontics often have a lifetime maximum benefit, which might not cover the full cost of treatment. You may need to pay some costs out-of-pocket, so understanding these limits is crucial.

Check for coverage limits

When it comes to orthodontic treatment, it's essential to understand the specifics of your insurance plan and any coverage limits. Here are some key considerations:

• Type of Insurance: Employer-sponsored dental insurance plans and private dental insurance plans often offer coverage for orthodontic treatment. Additionally, Medicaid offers orthodontic coverage for individuals under the age of 21 in many states.
• Age Limitations: Some insurance plans provide orthodontic coverage only for beneficiaries under a specific age, typically 18 or 21. However, some plans also extend coverage for adult orthodontics.
• Coverage Amount: Plans that cover orthodontics often have a lifetime maximum benefit, which may not cover the full treatment cost. The lifetime maximum can range from $1,000 to $3,000, and plans typically pay 50% up to this limit.
• Waiting Periods: Some insurance policies have waiting periods, requiring you to be enrolled in the plan for a certain period before orthodontic coverage applies.
• Medically Necessary Orthodontics: Orthodontic treatment may be deemed medically necessary in cases of severe malocclusion, which interferes with oral functions. Some insurance plans offer more comprehensive coverage for these cases.
• In-Network Providers: Insurance companies usually have a network of providers with negotiated discounted rates. Choosing an in-network orthodontist can result in lower out-of-pocket costs.
• Out-of-Network Coverage: If you have a Preferred Provider Organization (PPO) dental plan, it may offer some level of coverage for out-of-network providers, but your out-of-pocket expenses will likely be higher. Dental Health Maintenance Organization (DHMO) plans typically do not cover out-of-network care unless it's an emergency.
• Plan Details: Every dental insurance plan is different, and it's crucial to understand the specifics of your plan. Contact your insurance provider to clarify coverage details, including age restrictions, lifetime maximums, waiting periods, and your expected out-of-pocket expenses.

Understand eligibility for discounts

Understanding your eligibility for discounts on orthodontic services is an important step in managing the costs of your treatment. Here are some key points to help you navigate eligibility for discounts:

Types of Insurance

Firstly, it is important to understand the type of insurance plan you have. Employer-sponsored dental insurance plans and private dental insurance plans often offer some form of coverage for orthodontic treatment. Additionally, Medicaid offers orthodontic coverage for individuals under the age of 21 in many states. If you fall under a certain income threshold, you may qualify for Medicaid assistance, which includes coverage for medically necessary procedures, such as braces for children.

Age Limitations

Age restrictions are a common factor in insurance plans offering orthodontic coverage. Many plans provide coverage only for beneficiaries under a certain age, typically 18 or 21. However, some plans do offer coverage for adult orthodontics, so it is important to review your specific plan details.

Coverage Amount

Insurance plans that cover orthodontics often have a lifetime maximum benefit, which may not cover the full cost of treatment. This means there is a maximum amount that the insurance company will pay towards orthodontic treatment over the lifetime of the policyholder. Once this maximum has been reached, the patient becomes responsible for all subsequent orthodontic costs.

Waiting Periods

Some insurance policies require a waiting period before you can claim benefits for orthodontic treatment. This means that there is a specified amount of time that you need to be enrolled in the plan before the coverage for orthodontics applies. It is important to check if your plan has any waiting periods to avoid unexpected costs.

In-Network Providers

Insurance companies typically have a network of providers with whom they have negotiated discounted rates. Using an in-network orthodontist for your treatment will generally result in lower out-of-pocket costs. Review your insurance plan's list of in-network providers and confirm their coverage to take advantage of these potential discounts.

Medically Necessary Orthodontics

In some cases, orthodontic treatment is deemed medically necessary, such as when severe malocclusion interferes with oral functions like eating or speaking. Some insurance plans may offer more comprehensive coverage or higher discounts for these medically necessary cases.

Discount Dental Plans

If your dental insurance plan does not cover orthodontic services, you may want to consider a discount dental plan. Unlike traditional insurance, these plans require an annual fee in exchange for significant discounts on dental services, including orthodontic treatment. This can be a cost-effective alternative to traditional insurance if you require orthodontic care.

Government Programs

Children, teenagers, and some adults may be eligible for government assistance programs like Medicaid or the Children's Health Insurance Program (CHIP), which often cover orthodontic treatments. These programs can provide financial assistance and help make orthodontic care more accessible.

Flexible Spending Accounts (FSA) or Health Savings Accounts (HSA)

If you have an FSA or HSA, you can use these pre-tax savings accounts to pay for your orthodontic treatment. This can help reduce the overall cost of your treatment by utilizing tax benefits.

To summarize, understanding your eligibility for discounts on orthodontic services involves reviewing your insurance plan details, considering alternative options like discount dental plans, and exploring potential government assistance programs. By proactively researching these options, you can make informed decisions that suit your orthodontic needs and financial situation.

Submit a claim online

To submit an orthodontic claim online, you can use the Provider Tools platform. First, you'll need to register for an account and log in to your dashboard. From there, select 'Submit claim'. You only need to submit one claim at the time of the initial banding. There's no need to submit additional claims for monthly adjustments, as Delta Dental calculates payment based on that first claim, which includes complete treatment and fee information.

To keep track of your claims, simply select 'My claims' in the Provider Tools dashboard.

For orthodontic claims, submit a single claim at the time of the initial banding, including the following information:

• A description of the dentition
• The procedure code with a description of the appliance and treatment
• The banding date and the estimated number of active treatment months
• The total fee you intend to collect for services (including the initial down payment and monthly fee)

If applicable, you should also include:

• The amount paid by a previous dental carrier
• The name and procedure code of appliances used to control a harmful habit
• Any dual coverage information

You don't need to submit x-rays or radiographs unless specifically asked to do so.

Frequently asked questions