Orthodontic coverage is often a separate benefit in a dental insurance contract. Coverages for orthodontic treatment usually are at the 50% level. To determine your orthodontic coverage, it is suggested that you call the insurance company and ask the following questions:
Does the plan cover orthodontic treatment (braces)? If so, at what percentage?
Are there any limitations to coverage (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, the orthodontic office will 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 receipt. Attach this to one of your Dental Claim Forms (filled in by the subscriber) and submit both to your insurance company who will reimburse you directly.
Points to remember:
1) Orthodontic specialists do not accept assigned payment from insurance companies.
2) It is not necessary for the orthodontic specialist to fill in the Dental Claim Form as no dental codes are required for orthodontic coverage.
3) Only one Certified Specialist in Orthodontics Standard Information Form is necessary to predetermine benefits, and once approved, no other insurance forms are necessary from the orthodontic office.
CAO ORTHODONTIC INSURANCE GUIDELINES
The following are guidelines to assist patients with their submission of orthodontic insurance predeterminations:
1) COMPLETE one of your Dental Claim Forms in the usual manner.
2) COMPLETE the “Patient Identification” portion of the Certified Specialist in Orthodontics Standard Information Form that you receive from your Orthodontist.
3) ATTACH the white copy of the Standard Information Form to your Dental Claim Form and 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 a receipt. Attach that receipt to a Certified Specialist in Orthodontics Standard Information Form. Attach these items to your Dental Claim Form and submit it to your carrier. It is not necessary for the orthodontic specialist to complete the Dental Claim Form. NO CODES ARE REQUIRED FOR ANY ORTHODONTIC CLAIM SUBMISSIONS.
When payment is made to the orthodontic office for ongoing active treatment, the office will provide you with a receipt. Attach that receipt to a Dental Claim Form and submit this to your carrier. The orthodontic office does not need to provide any insurance forms at this point, only receipts, as the orthodontic treatment has been pre-determined already by the carrier. Thus there is no need for any further monthly or quarterly Standard Insurance Forms from the orthodontic office once you have received approval from the insurance company. Receipts attached to your Dental Claim Form and submitted to your carrier are sufficient proof of the continuation of treatment.
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.
Coordination 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.