Understanding Your Orthodontic Insurance


1) The total case fee for your orthodontic treatment is submitted to your insurance company when treatment begins. The “banding date” is the date on which treatment officially begins; this is the day bands or brackets are placed on the teeth. Placing spacers or separators does not constitute treatment starting.


2) Insurance payments are paid to the orthodontic office either monthly, quarterly, or annually. It is a rare exception that a one-time payment for the entire lifetime maximum is made initially.


3) During orthodontic treatment, if insurance coverage is interrupted for any reason, (i.e. a job change, your employer changes insurance companies, your coverage is dropped, or treatment ends) insurance payments stop. If an insurance change occurs during treatment, it is the patient’s responsibility to inform the office. A new insurance company will not know you are in orthodontic treatment. A new claim must be filed with the new insurance company because they won't pay if they don’t know about it.


4) When our office confirms orthodontic benefits, the insurance company is very clear that the benefit information we are given is an estimate and no guarantee of payment. In our orthodontic financial agreement, the insurance allowance we take assignment for is an “estimate.” We never know for sure how long or even if we will be paid until it actually happens. If for any reason the total insurance assignment is not paid as expected, it becomes the responsibility of the patient or responsible party. If the insurance company retains a portion of the benefit to cover your deductible, you will be responsible for reimbursing that deductible to our office.


5) Our office is happy to file an insurance claim on our patient’s behalf; however, once the initial carrier has paid the insurance balance in full, we will be unable to file an additional claim should you become insured with another carrier. We will be happy to provide you with the information you need to file the claim yourself.

6) Some insurance companies use orthodontic benefits to pay for procedures done at other providers' offices, especially oral surgery. If a procedure from another providers office is paid for with orthodontic benefits, you will be responsible for the difference not paid to our office by the insurance Company. 


7) Some insurance companies place a contingency of medical necessity on  orthodontic claim payments. If your insurance company determines that your treatment is not medically necessary, you will be responsible for the estimated insurance portion. 


8) Our office may not be aware of your policy's status under the Affordable Care Act (ACA). Under these provisions, benefits are only provided for children with serious orthodontic impairment resulting from congenital abnormalities that affect their daily ability to function, like eating and speaking. Your insurance company will review your child's case before approving or denying coverage for the treatment. 


This is a general explanation. Please keep in mind that your policy maybe different.


Fremont Office 

San Ramon Office

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