Insurance Billing Nuances
Keep the following factors in mind when billing clear aligner treatment to your patient’s insurance.
- Ortho claims are determined and paid over the course of treatment. If eligibility is terminated during the course of treatment, ortho payments stop!
- Ortho is considered a separate benefit and has a once per lifetime eligibility.
- Most carriers pay a percentage of the total fee up to the ortho lifetime max.
- Many carriers are providing adult ortho 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/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 Class I, II, 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
Examples of Ortho Coverage Max
The ortho max is $1500, ortho benefit is 50%
Insurance will pay 50% of UCR (usual, customary, and reasonable charge) or contracted rate (depending on out of network/ in network status) up to the lifetime max of $1500.
Orthodontic Billing Codes
D8660 Orthodontic Exam & Evaluation (Separate from D0150 or
D0350 2D Oral/ Facial Photo Images
D0330 Panoramic Image (Once Every 2-5 Years, Depending on
D0470 Diagnostic Casts / Study Models (Scans Count)
D8090 Comprehensive Tx of The Adult Dentition
D8040 Limited Orthodontic treatment: adult dentition (use for
single arch cases)
D8670 Periodic orthodontic treatment visit (Code for
D8999 Miscellaneous code - Clear Aligners (Allowable
upcharge from your contracted rate on some plans)
D9951 Limited occlusal adjustment
(occ. equilibration, Incisal edge reshaping) Most major
carriers could cover up to 50-80% (plans may vary). Bill
separately once occlusal adjustment is done.
We recommend adding the following questions to your insurance verification process/form.
- Ortho 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
Example of Required Fields on Ortho Claim