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Understanding Your Orthodontic Insurance

The ins and outs of orthodontic coverage and your dental insurance.

Dental Insurance orthodontic insurance

At Bloom Orthodontics, we understand that orthodontic treatment is an investment. Some employers offer orthodontic insurance to offset the out-of-pocket investment for orthodontic treatment. Insurance companies do not automatically cover dental and orthodontic care, orthodontic insurance is covered under dental insurance as a supplemental benefit. Orthodontic insurance works differently than most medical insurance benefits. To help you better understand your insurance coverage, here are a few key points.

ELIGIBILITY: If you have orthodontic coverage through your employer, we want to verify that your policy is active and effective. Therefore, we always try to speak to your insurance company prior to your exam to make sure you are eligible for orthodontic coverage. Even though your employer may offer orthodontic coverage, that does not mean you are eligible. Some policies require you to work a minimum number of hours per week, or there may be a 6-12 month waiting period for a new employee.

DUAL COVERAGE: Double coverage occurs when a patient is enrolled in two active policies. Our office will do our best to help determine how much each policy should pay. Note: Some exclusions may be present on both.

TWO-PHASE TREATMENT: In the case that the doctor recommends two phases of treatment, our office may only receive a portion of your insurance benefit for phase I. Any unused benefit may be applied towards phase II, as long as the policy is still active. 

ADDITIONAL PROCEDURES: If extractions or exposures are needed to accomplish orthodontic treatment, please note that these procedures are often billed from a dental benefit, but in rare instances, they will be billed from your orthodontic benefit. In this instance, our office will not receive the full anticipated benefit and the remaining balance will be transferred to your account. 

PAYMENTS: It is important to note that orthodontic benefits are rarely ever paid out upfront. Depending on your insurance company, payments will be spread out over the course of treatment in monthly, quarterly, or yearly installments. Therefore, coverage MUST remain active throughout the course of treatment to receive the full benefits.

STARTING DATE: The start date is the date the appliances/braces are placed on your teeth. Your insurance will need this date in order to process claims.  An insurance claim cannot be submitted before treatment officially begins, even if it is the end of the year and your benefit expires with the new year. Back dating insurance claims is considered insurance fraud.

WORK IN PROGRESS: Please inform our office immediately of any new coverage so we can submit a claim in a timely manner. It’s not unusual for your new insurance company to prorate your benefit based on the prior coverage paid and/or remaining treatment time. Note: Not all plans allow for “Work In Progress”. 

BENEFITS: Every plan offers a different level of benefits. Generally, an orthodontic benefit is separate from your regular dental benefit. In most cases, orthodontic benefits have a one-time use benefit. It’s important to note that maximums rarely cover half of a full comprehensive fee.

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