Creating Clear Aligner Insurance Claims

Overview: This guide explains the lifecycle, eligibility, and filing requirements for clear aligner orthodontic insurance claims to ensure accurate reimbursement. 

Understand Orthodontic Billing Nuances

Orthodontic insurance benefits function differently than general dental benefits. Practice owners should consider these factors when billing for clear aligner treatment:

• Course of Treatment Payments: Insurance carriers pay orthodontic claims over the duration of the treatment. If a patient loses insurance eligibility during treatment, orthodontic payments from the carrier will stop immediately.

• Lifetime Eligibility: Orthodontics is typically a separate benefit with a once-per-lifetime eligibility limit per patient.

• Payment Schedules: Most carriers pay a portion of the total fee upfront. The carrier pays the remaining balance on a monthly, quarterly, semi-annual, or annual schedule.

• Adult Coverage Limits: Many insurance plans now include adult orthodontic coverage, though some carriers still apply age limits (e.g., 19 or 26 years old).

• Claim Filing Frequency: While most major carriers only require one initial claim for automatic payments, some carriers require the provider to file continuous claims monthly or quarterly.

File Clear Aligner Insurance Claims

To prevent processing delays, ensure all orthodontic claims include the following specific data points:

• Malocclusion Description: Clearly state the malocclusion class (Class I, II, or III).

• Procedure Date: The date of the aligner delivery must match the date entered in Box 41 of the claim form.

• Fee Breakdown: Include the total treatment fee, the initial down payment amount, and the scheduled monthly payment.

• Treatment Duration: Provide the estimated total number of months for the treatment plan.

• Upgrade Charges: Explicitly list any clear aligner upgrade charges if applicable.

Calculate Orthodontic Coverage Maximums

Carriers usually pay a percentage of the Usual, Customary, and Reasonable (UCR) charge or the contracted rate up to a lifetime maximum.

• Example Scenario: If a patient has a lifetime orthodontic maximum of $1,500 and a 50% benefit level, the insurance will pay 50% of the covered fee until the $1,500 limit is reached.

Review Orthodontic Billing Codes

Use the following ADA codes to document and bill for various stages of orthodontic care:

Verify Orthodontic Insurance Coverage

Ask the following questions during the insurance verification process to ensure accurate patient cost estimates:

1. What is the orthodontic lifetime maximum?

2. What is the coverage percentage for orthodontics?

3. Are there age limitations for adult orthodontic care?

4. Are records codes (D0350, D0330) considered part of the preventative or orthodontic benefit?

5. What is the required claim submission frequency?

6. What percentage of the total benefit is paid at the time of placement?

Related Information

• Access the Dandy Digital Dental Lab Ecosystem

• Clear aligners instructions for use (IFU)

• Identify Malocclusion for Clear Aligner Cases