FYI

Orthodontic claims involve unique documentation and payment requirements that differ from other dental services. Submitting complete information the first time can help minimize delays, reduce follow-up requests and support accurate benefit determinations.
 

Orthodontic claim submission checklist

Before submitting your next orthodontic claim, confirm that you've included:

• Banding/appliance insertion date
• Estimated treatment length
• Treatment description and appliance type
• Total treatment fee
• Down payment amount
• Monthly payment amount
• Dual coverage details, when applicable
• Transfer case indicator, if applicable
• Prior treatment information, if applicable

Understanding orthodontic payment structures

Unlike many dental procedures, orthodontic benefits are often paid over the course of treatment. Once the banding or appliance insertion date is received, the remaining installments may be established automatically. Providers may receive information regarding future installment payments as treatment progresses.

Reminder: Monthly orthodontic visits should not be submitted as separate claims. Periodic treatment visits are generally included in the orthodontic treatment fee.
 

Documentation requirements matter

For orthodontic procedures (D8010-D8090), a clinical narrative should include:

• Diagnosis
• Orthodontic treatment type
• Expected treatment length

Providers should also maintain laboratory invoices associated with orthodontic appliances as part of the patient's treatment record.

To help streamline processing:

• Include the banding date
• Include treatment length
• Clearly document transfer cases
• Maintain supporting records

Do not submit radiographs or diagnostic casts unless specifically requested.

Tip: Review the Claim Submission Guidelines section of the Provider Handbook in Provider Tools for more information.
 

Common orthodontic claim scenarios

Patient loses coverage during active treatment

Orthodontic benefits are often tied to patient eligibility. When eligibility changes during treatment, remaining benefits may need to be recalculated based on the patient's coverage status and plan provisions. Providers should verify eligibility regularly throughout treatment.  
 

Change in insurance carrier during treatment

When a patient becomes covered under Delta Dental after orthodontic treatment has already begun, benefits may be prorated based on the remaining eligible months of treatment. Coverage is typically calculated by prorating treatment months that occurred before the patient's effective date, subject to the terms and limitations of the applicable benefit plan.
 

Transfer orthodontic cases

Transfer cases should be clearly identified on the claim. The new provider should indicate that the patient transferred treatment and include the first adjustment date as the treatment start date for the transfer claim. Remaining orthodontic benefits are then calculated based on available benefits and any applicable maximums.
 

Treatment termination due to office closure or provider retirement

When an orthodontic office closes, a treating orthodontist retires or a provider is otherwise unable to continue active treatment, the provider must notify Delta Dental and submit an updated orthodontic claim to accurately reflect the status of treatment in progress.

The updated claim should include:

• The last date of active orthodontic treatment with treating provider.
• The reason treatment ended (e.g., provider retirement, office closure, relocation, provider departure or other circumstances preventing continuation of treatment).
• The patient's current treatment status at the time services ceased.
• The number of remaining adjustments or estimated treatment remaining, if applicable.
• Any transfer-of-care information if treatment will be completed by another orthodontic provider.
• The date orthodontic appliances were removed, if applicable.

Providers should maintain supporting clinical documentation and be prepared to provide treatment records upon request to assist with continuity of care and review of any remaining orthodontic benefits. If a patient transfers to another orthodontist because of a provider retirement or office closure, clearly identify the case as a transfer case and include all available treatment dates and supporting documentation to facilitate efficient claim processing.

Providers who are ceasing orthodontic services should maintain an active point of contact for records requests.
 

Missing banding date documentation

The banding or appliance insertion date is one of the most important pieces of information required for orthodontic claim processing. Missing dates frequently result in claim delays and requests for additional information. Always include the date on the initial submission.  
 

Clear aligners

Charges for clear aligners, including products such as Invisalign® and SureSmile®, should be reported using the appropriate orthodontic treatment code (D8010-D8090). Benefits are based on approved orthodontic treatment allowances and not on the specific appliance selected.

For direct-to-consumer aligner treatment, providers must complete and retain a Treating Dentist Attestation Form in the patient record before initiating treatment.
 

Retainers and retainer replacements

Many provider questions involve retainers, especially replacement retainers. Remember:

• Orthodontic treatment allowances generally include retention and post-treatment stabilization.
• Initial retainer placement is considered part of orthodontic treatment and is not separately billable by the treating orthodontist.
• Repair or replacement appliances are generally not covered under most plans and may be the patient's responsibility.

Treatment extensions and early completion

If treatment is completed ahead of schedule, providers should notify Delta Dental and include the date appliances were removed and treatment was completed. This allows any remaining scheduled payments to be reviewed appropriately.

Similarly, when treatment extends beyond the original estimate, documentation should clearly explain the circumstances and treatment status to support claim review. (This recommendation is based on the need for complete claim documentation; the Provider Handbook in Provider Tools specifically addresses early completion and treatment status reporting.)

Complete documentation, accurate treatment dates and clear identification of transfer or treatment-in-progress cases are the most effective ways to avoid processing delays and ensure orthodontic claims are reviewed efficiently.