A Guide for Clear Aligner Insurance Claims

Navigating the complexities of insurance billing for clear aligner treatments can be as intricate as the treatment itself.

This article is a comprehensive guide to help you understand the nuances of orthodontic insurance claims, ensuring you can secure the proper coverage for your patient’s orthodontic care. This includes:

• The lifecycle of ortho claims
• Considerations for lifetime eligibility
• Variations in coverage by major carriers
• Specifics on claim filing to avoid processing delays.

Our hope is that this will empower your practice with the knowledge needed to navigate the intricacies of insurance billing for orthodontic care, maximizing the benefits for your patients while maintaining efficient operations.

Insurance Billing Nuances

Remember the following factors when billing clear aligner treatment to your patient’s insurance:

• Orthodontic claims are determined and paid over the course of treatment. If eligibility is terminated during the course of treatment, orthodontic payments will stop!
• Orthodontics is considered a separate benefit and has a once-per-lifetime eligibility.
• Most carriers pay a percentage of the total fee up to the orthodontic lifetime maximum.
• Many carriers are providing adult orthodontic coverage. Some may or may not have age limits.
  • I.e., 19, 26, or no limit.
• Carriers will pay a portion of the submitted charges upfront, and the remainder is paid either monthly, quarterly, semi-annually, or annually.
• Most major carriers require only an initial claim and will pay automatically based on a schedule. ݴ Some carriers will require continuous claim filing by the provider (i.e., monthly or quarterly).

Claim-Filing Information

When filing a claim, be sure to include the information below to avoid delays in claim processing. 

• Description of the malocclusion Classes I, II, and III
• Procedure date (actual date of aligner delivery must match the date in box 41)
• Total treatment fee
• Down payment
• Monthly Payment
• Estimated total months of treatment
• Clear aligner upgrade charge 

Example of an Ortho Coverage Max

The ortho max is $1500, and the ortho benefit is 50%

Insurance will pay 50% of the UCR (usual, customary, and reasonable charge) or contracted rate (depending on out-of-network or in-network status) up to the lifetime maximum of $1500.

Orthodontic Billing Codes

Insurance verification 

We recommend adding the following questions to your insurance verification process or form:

• Orthodontic lifetime max
• Coverage percentage
• Age Limitations
• If records codes are covered and considered part of the preventative, basic, or orthodontic benefit
• Claim submission frequency (i.e., monthly, quarterly, etc.)
• Percentage paid at placement