Insurance Coverage

Orthodontic specialists do not accept assigned payment from insurance companies. This policy is designed to protect the rights of patients for treatments which the insurance carrier could deem optional. As you may know many general dentists accept direct payment form insurance carriers . The result of this direct billing has led many insurance carriers to request diagnostic and treatment information from the dentist so they may determine if the treatments proposed are necessary by their standards. This process leaves your benefit plan in charge of approving your treatment plan . (Over time we feel this method of billing will lead largely to rejection of many orthodontic treatments.)

Orthodontic coverage is often a separate benefit in a dental insurance contract. Coverages for orthodontic treatment usually are at the 50% to 60% level. 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:

1) Does the plan cover orthodontic treatment (braces)?

2) What percentage and dollar limits are in effect.

3) Are there any exclusions to treatment? i.e. age limits (some plans will not cover orthodontics for patients over the age of 18)

In most cases due to confidentially issues most plans will not discuss your coverage with the orthodontic office.  Your certified specialist will make financial arrangements with you once a treatment plan has been set and provide you with a Canadian Association of Orthodontists Certified Specialist Standard Information Form. This form must be sent immediately to the insurance company. 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. Some insurance companies will not reimburse patients for claims that are over 12 months old . It is best to submit your claim receipts as you receive them
Patient may claim from more than one insurance company at a time. You will need to determine this directly from each carrier.

Dual coverage from more than one plan

In a situation where two parties both have orthodontic coverage, the person with the birth dates earlier in the year is considered the primary or first subscriber (e.g. January birth date 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.

To learn more, talk to an orthodontic specialist.