With changing dental insurance reimbursement rates, and rules and regulations, the complexity of dental billing continues to increase. This has led many practices to rely on dental billing experts to manage coding and patient billing. The dental billing services that these professionals provide include insurance verification, working outstanding claims and posting insurance payments on a daily basis, and appeals to overturn denials. Such support is important for orthodontics reimbursement, which has special guidelines as orthodontic treatments can span over multiple plan years.
Orthodontics, which relates to correction of abnormal dental relationships, including facial structures and neuromuscular abnormalities, involves “the use of any appliance, in or out of the mouth, removable or fixed, or any surgical procedure designed to redirect teeth and surrounding tissues” (www.hca.wa.gov). There are three categories of orthodontic treatment: Limited, Interceptive and Comprehensive. The definitions given in the ADA CDT code book are as follows:
- Limited Orthodontic Treatment – This is defined as orthodontic treatment with a limited objective, not involving the entire dentition. It may be directed at the only existing problem, or at only one aspect of a larger problem.
- Interceptive Orthodontic Treatment – This refers to procedures to lessen the severity or future effects of a malformation and to eliminate its cause. It can be considered an extension of preventive orthodontics that may include localized tooth movement. Such treatment may occur in the primary or transitional dentition.
- Comprehensive Orthodontic Treatment – This involves treating the dentition as a whole. Treatment usually, but not necessarily, uses fixed orthodontic appliances or braces. Comprehensive Orthodontic Treatment may incorporate more than one phase of treatment, with specific objectives at various stages of dentofacial development.
- Insurance verification: The patient must be eligible for orthodontic benefits, and so the first step would be determining eligibility. As orthodontic benefits differ significantly from policy to policy, it is essential to contact the patient’s insurance carrier for dental insurance verification and coverage. Moreover, some dental plans provide benefits only to children, while others provide benefits to adults.
- Benefits verification is carried out before the patient’s office visit. Information verified would include: the name of the insured (subscriber), date of birth, social security number, or other identification number; the name of the patient or beneficiary; the insurance company’s name and phone number; and the policy number. The insurance verification specialist will contact the insurance company to find out the lifetime (or sometimes annual) maximum, percentage of the fee paid by the carrier, copayment, and deductible, and limitations such as age and dependency status.
- Coordination of benefits (COB): This is important when a patient has dual coverage or is covered by more than one insurance plan (dual coverage). After identifying the primary and secondary carriers, claims are submitted in accordance with the guidelines that determine in what order the dental office must bill each health insurance plan.
- Completion of the insurance form: Dental billing service providers submit orthodontic claims electronically with all the information necessary to help the payer determine benefits quickly. Leading insurance company Aetna specifies that this information should include: banding date; number of months of treatment; assignment of benefits information; ADA code; total case fee; primary insurance provider explanation of benefits (if COB is necessary), and prior insurance carrier information, including deductible, coinsurance/copay, maximum and amount paid to date (if patient is continuing active treatment).
Orthodontic codes differ for treatment performed in the primary, mixed, adolescent, and adult dentitions. Codes are also defined by whether the treatment is limited, interceptive, or comprehensive:
Orthodontic retainers – D8220-Fixed appliance therapy, D8210–Removal appliance therapy, and D8680-Orthodontic retention
Limited orthodontic treatment – D8010-Limited orthodontic treatment of the primary dentition; D8020-Limited orthodontic treatment of the transitional dentition; D8030-Limited orthodontic treatment of the adolescent dentition; D8040-Limited orthodontic treatment of the adult dentition
Comprehensive orthodontic treatment – D8070-Comprehensive orthodontic treatment of the transitional dentition; D80-Comprehensive orthodontic treatment of the adolescent dentition; D8090-Comprehensive orthodontic treatment of the adult dentition
Multiple phase treatment plans would require the use of comprehensive orthodontic procedure codes. To code procedures correctly, dental practices need to be knowledgeable about the latest CDT codes and diagnostic codes. CDT codes are sometimes redefined and clarified, and new codes added from time to time to define new procedures.
When it comes to submitting insurance claims for orthodontic treatments, outsourced dental billing services are a good option. Experienced medical billing companies that also specialize in dental billing have experts on the job. They follow established claim submission protocols to ensure that dental office receive maximum reimbursement for their services.
Checking the eligibility or benefit information prior to the patient’s consultation allows practitioners to provide a more organized consultation, and also helps patients evaluate their financial options more easily and quickly.
The insurance claims are then processed and monitored. Processing claims for orthodontic treatment and claims for general dental procedures is different in terms of how benefit payments are broken down and spread out across the course of treatment. Partnering with an experienced provider of dental billing services is essential to ensure accurate and timely reimbursement.