Orthodontic coverage is often a separate benefit in a dental insurance contract. Coverages for orthodontic treatment usually are at the 50% level. Orthodontic specialists do not accept assigned payment from insurance companies.
To determine your orthodontic coverage, it is suggested that you call the insurance company or speak with the plan administrator where you work and ask the following questions:
- Does the plan cover orthodontic treatment (braces)?
- If so, at what percentage?
- Are there any limitations to coverage, eg. age, maximum dollar amount, etc.?
Once you have established that you have orthodontic coverage, and after financial arrangements have been made with the orthodontic specialist, it is the obligation of the orthodontic office to provide you with a Canadian Association of Orthodontists Certified Specialist in Orthodontics Standard Information Form. Send this form immediately to the insurance company. The carrier will write to you directly about your coverage. When you make a payment to the orthodontic office, you will be provided with a claim form. Sign the dental claim form and submit to your insurance company who will reimburse you directly. Some insurance companies will allow you to submit online once the predetermination has been sent in and is on your file. You will need the orthodontist’s unique identification number and the procedure code. In this case, keep the paper copy on your files in the event of an audit by your insurance company.
CAO ORTHODONTIC INSURANCE GUIDELINES
The following are guidelines to assist patients with their submission of orthodontic insurance predeterminations:
- COMPLETE one of your Dental Claim Forms in the usual manner.
- COMPLETE the “Patient Identification” portion of the Certified Specialist in Orthodontics Standard Information Form that you receive from your Orthodontic specialist.
- Submit it to your insurance carrier.
Your insurance carrier will advise you directly, in writing, how much they will cover. If you do not hear back from your carrier within 2-3 weeks, it is suggested that you give them a call.
For Submission of Claims
The following guidelines apply to examinations, diagnostic records and ongoing active treatment.
When payment is made to the orthodontic office for examinations and diagnostic records, you will be provided with an insurance claim form. Sign the Dental Claim Form and submit it to your carrier.
When payment is made or coming due to the orthodontic office for ongoing active treatment, the office will provide you with an insurance form at your appointments. Submit this Dental Claim Form to your carrier on or after the date shown.
It is suggested that the subscriber keep a photocopy of all receipts submitted to your carrier as any unpaid portion may be able to be claimed as a deduction on your income tax return.
Co-Ordination of Benefits
In a situation where two parties both have orthodontic coverage, the person with the birthdate earlier in the year is considered the primary or first subscriber (eg January birthdate as opposed to August). The primary subscriber sends in the documents as outlined and then sends the reply from the primary carrier to the secondary carrier for adjudication.