ORTHODONTIC INSURANCE - Cloud Object Storage · PDF fileorthodontic insurance coverage before the patient orthodontic consultation, treatment and fee presentation. STEP 1 - Get patient

ORTHODONTICINSURANCE

GUIDEMaximizing Orthodontic Insurance Benefits for Invisalign® Patients

Maximizing Orthodontic Insurance Benefits for Invisalign® Patients Maximizing Orthodontic Insurance Benefits for Invisalign® Patients

*Disclaimer: Any use of the CDT and/or Code on Dental Procedures and Nomenclature by users of this Guide separate from the purpose of this Guide requires a valid CDT license from ADA.

Users of this Guide may not:

1) Alter, amend or modify the Code on Dental Procedures and Nomenclature or other portions of the CDT.

2) Resell, transmit or distribute copies of the Code or other portions of the CDT or electronic files or printed documents that contain the Code or other ports of the CDT.

3) Print out copies, download or store on User’s computer system electronic files of the Code or other portions of the CDT as reproduced Electronic Publication(s), except for User’s private or business use – but not for resale or distribution.

4) Remove any CDT copyright or other proprietary notices, labels or marks for the Code or other portions of the CDT.

5) Use this Guide to provide consulting, time-sharing, application service provider, or outsourcing services or to act as a service bureau operation.

Current Dental Terminology (CDT), ©2011 American Dental Association. All rights reserved www.ada.org.Developed for Align Technology, Inc. by Lourdes Berlanga. © All rights reserved.

1

INTRODUCTION

This comprehensive guide was developed for the purpose of teaching and implementing a system which will assist in maximizing orthodontic insurance benefits when providing dental and orthodontic care for Invisalign patients. The best business practices introduced in these materials have proven themselves over time to accomplish this goal with results consistently superior to those achieved by other means.

These materials offer an standardized system which can be applied to all dental offices, while balancing each office’s unique needs with the purpose of delivering the highest quality patient care and practice profitability. This information is presented in a very specific sequence. It is highly recommended that you read this guide in the intended sequence to optimize your understanding of the material and maximize insurance benefits for Invisalign patients.

ORTHODONTIC INSURANCE 101 2

BEFORE THE ORTHODONTIC CONSULTATION 3

STEP 1 - Get All the Necessary Information STEP 2 - Call the Insurance Company to Verify Patient’s Orthodontic Benefits STEP 3 - Review all Patient and Insurance Information

DURING THE ORTHODONTIC CONSULTATION 5

STEP 1 - Examine Patient and Present Treatment Recommendation STEP 2 - Present Payment Options STEP 3 - Get Contract and Consents Signed STEP 4 - Collect Payment STEP 5 - Obtain Invisalign Required Records

AFTER THE ORTHODONTIC CONSULTATION 6

STEP 1 - Submit Signed Agreements to the 3rd Party Financial InstitutionSTEP 2 - Initiate Invisalign Submission Process STEP 3 - Review and Approve the ClinCheck® Treatment Plan STEP 4 - Deliver the Invisalign Aligners STEP 5 - Submit the Insurance Claim

IMPORTANT TIPS 8 COMMON CDT ORTHODONTIC CODES 9 EXAMPLES

PAYMENT ARRANGEMENTS 10

ADA DENTAL CLAIM FORM

TRUTH IN LENDING CONTRACT

INSURANCE GUIDE SUMMARY


2 3

ORTHODONTIC INSURANCE 101

ORTHODONTICS AND ORAL HEALTH

Orthodontic treatment corrects malocclusion and misalignment. Proper teeth alignment may help patients avoid the negative effects of dental, periodontal and TMJ diseases. Technological advances in clear aligner therapy by Invisalign® offer dental professionals with ever-improving tools to provide orthodontic treatment for patients of all ages.

ORTHODONTICS AND DENTAL INSURANCE

All dental insurance plans use the same codes to refer to the diverse number of dental procedures. The Current Dental Terminology (CDT) codes were developed and are maintained by the American Dental Association for reporting and billing to dental insurance plans. The set of codes which relate to Orthodontic billing start with the prefix D8XXX, as in: D8090 Comprehensive orthodontic treatment of the adult.

While insurance companies offer practices access to more patients, they often require doctors to contractually agree to reduced treatment fees for certain dental and/or orthodontic procedures.

Before providing orthodontic treatment, it is important to review and re-negotiate contracted orthodontic fees as needed to maximize the profitability of orthodontic treatment with Invisalign. To re-negotiate contracted orthodontic fees, call the provider’s services department of each contracted insurance company, and periodically file updated fee schedules.

There are hundreds of dental insurance and dental discount plans offering policies with various degrees of coverage and billing requirements for the same dental procedures. Though these insurance plans may share, mix and match similar characteristics, in essence, they can be divided into two main categories:

1. Indemnity dental insurance plans: The doctor is not contractually obligated with the insurance company. Indemnity plans pay specific percentages of UCR-based (Usual, Customary, and Reasonable) fee schedules or “Table of Allowances” where each

allowed procedure has an associated set dollar amount that the plan will consider for payment when that particular service is required. The patient is responsible to pay the dental provider’s fees in full regardless of the insurance company’s UCR or “allowed” fees. The insurance company does not determine the treatment fee. Therefore, the practice is not limited when charging for the services they provide.

2. Managed Care dental insurance plans: The doctor is contractually obligated with the insurance company. The insurance company determines the treatment fee. There are essentially two different types of managed dental plans:

HMO (Capitation dental plans): The doctor is paid a fixed amount, typically monthly, for each patient in his/her roster (per capita/ per head) whether or not the patient receives treatment. In turn, the doctor is required to provide any and all needed dental treatment for these individuals during the negotiated time frame.

PPO or EPO (Preferred Provider Organization or Exclusive Provider Organization): In exchange for an increased base of patients, the doctor has agreed to charge a discounted rate for treatment provided to members of a specific dental plan. PPOs and EPOs are similar in nature with the exception that EPOs do not offer the option of receiving dental treatment from a doctor who is outside the dental insurance company’s network of providers. PPO patients may choose a provider outside the preferred network but they may receive a reduced benefit.

ORTHODONTIC INSURANCE PAYMENTS ARE COMMONLY PAID OVER THE LENGTH OF TREATMENT

It is important to understand each insurance plan’s orthodontic payment schedule when determining payment options for the patient. An insurance plan which pays a high percentage of the initial payment may increase the flexibility of the offered payment options, therefore, increasing the chances of converting the case.

Indemnity plans, PPO and EPO plans pay for orthodontic treatment over the treatment time with different payment schedules. Generally the insurance company makes an initial payment (20-25% of the total lifetime maximum benefit) when the first set of aligners is delivered and the remaining benefit is scheduled to be paid in monthly, quarterly or semi-annual payments.

For HMO (Capitation plans) insurance payments are not expected for orthodontic treatment unless otherwise negotiated with the insurance company. Usually the doctor is required to provide any and all needed dental treatment for these individuals during the negotiated time frame.

BEFORE THE ORTHODONTIC CONSULTATION

To establish the role of insurance in orthodontic treatment, it is very important to verify the patient’s orthodontic insurance coverage before the patient arrives. The doctor and the team will need to know about the patient’s insurance coverage for the orthodontic consultation, treatment and fee presentation.

STEP 1 - Get patient & subscriber information while scheduling the consultation. Obtain the following information from the patient (or guardian) while scheduling the Invisalign consultation appointment. This information will help you when you talk to the insurance representatives in Step 2:

Insurance name

Insurance phone number

Patient’s date of birth

Patient’s name

Patient’s address

Patient’s contact phone number

Subscriber’s name

Subscriber’s date of birth

Subscriber’s relationship to patient

Subscriber’s employer

Subscriber’s ID or Social Security number


4

STEP 2 - Call the insurance company to verify the patient’s orthodontic benefits

Once you have gathered all the above information, call the insurance company and ask the following questions before the patient comes in for the Initial Consultation appointment. Be sure to have the Doctor’s Provider Identification Number ready before you call.

Insurance Type: Indemnity, HMO, PPO or EPO?

Waiting Period: When is the patient eligible?

CONTRACTED FEE: Maximum total fee the doctor can charge for orthodontic treatment

Claims Department Address?

Deductible: Amount that the patient must pay before the Orthodontic benefit becomes available.

Plan or Group number?

Standard or non-Duplication of benefits: How is dual coverage handled?

Orthodontic Coverage: Available for Subscriber, Spouse, and Child?

Pre-existing Conditions: Will ongoing treatment be covered?

Age Limit: What is the maximum age to receive orthodontic coverage?

Billing schedule: Do claims need to be sent monthly, quarterly, semi-annually, or will the payments be remitted automatically? How often will payments be sent?

Lifetime Maximum Coverage: What is the available benefit for orthodontic treatment?

Preauthorization: Mandatory or recommended?

Remaining Lifetime Benefit: How much of the original benefit is still available?

Name of the Representative: Always make note of the representative who provided the information, you will need it in case of any billing disputes.

Percentage: What percentage of the orthodontic treatment orthodontic treatment fee would be covered by the insurance company?

Date: Make note of when you spoke to the representative.

STEP 3 - Review all Patient and Insurance Information Before the doctor and team meet with the patient, it is important for them to know the following information about the patient. Daily morning briefings with the entire team are highly recommended to review this information:

The insurance benefits have been verified: Type of Insurance, available orthodontic benefits, exclusion and limitations, etc.

Contracted Fee: Maximum amount that this patient can be charged for orthodontic treatment

Important: If the contracted fee is less than the Invisalign treatment fee; make sure the doctor is aware of this before recommending Invisalign

Patient’s main concerns and/or goals for orthodontic treatment.

For new patients, all necessary forms (Health history, contact information, financial responsibility, HIPAA for new patients) are correctly completed and signed.

TIPS:

If the insurance’s plan total allowed contracted fee for orthodontics is less than the orthodontic treatment fee charged by the practice, stop and take a moment to evaluate how to present the best treatment options to the patient. Providing orthodontic treatment with Invisalign for a patient with this type of coverage may not be profitable.

Plan enough time with the patient to take necessary x-rays and impressions to get the treatment started the same day.

Read the treatment notes to make sure that the patient is ready to proceed with orthodontic treatment, for example all restorations (fillings, crowns, etc.) needed prior to orthodontic treatment have been completed.

Ask the patients to bring all decision makers to the appointment to answer all possible questions.

DURING THE ORTHODONTIC CONSULTATION

The whole team is responsible for providing a positive orthodontic experience in a warm, professional environment and ensuring the success of the orthodontic consultation. During the initial orthodontic consultation, the Doctor is the clinical specialist and educator, and the Financial Coordinator is the patient’s advocate, helping patients make an important decision about their treatment options.

STEP 1 - Examine Patient and Present Treatment Recommendation

Assess clinical findings and determine treatment options

Review contractual insurance obligations

Present clinical findings, review treatment options and timing with patient

Answer all questions to assist the patient in choosing their best treatment option

STEP 2 - Present Payment Options

It is strongly recommended that the Financial Coordinator takes charge of Steps 3 to 5, in order to emphasize the Doctor’s clinical specialist role.

The Financial Coordinator determines total treatment fee after reviewing the Contracted Fee (maximum amount that this patient can be charged for orthodontic treatment).

Present to the patient the total treatment fee and the patient’s remaining balance after insurance (if any).

Be sure to spell out exactly what the treatment fee will cover as this will increase the value of treatment.

Clarify to the patient that the estimated insurance portion is determined by the insurance company, insurance coverage is not a guarantee of payment, and the patient is responsible for all fees not paid by the insurance company.

Formulate and discuss payment arrangements with the patient offering monthly payments with 3rd party financing first. (Refer to Payment Arrangements examples at the end of this Guide)

To get a commitment from the patient, always ask: “Which of these payment options fits your budget today?”

STEP 3 - Get Contract and Informed Consent Signed

Once the patient has made the decision to proceed with orthodontic treatment, there are a number of forms that should be completed and signed to reflect a legal agreement for services to be rendered, each party’s rights and responsibilities under the agreement, as well as all the risks and limitations of the treatment to be provided. The following should be completed and signed by the patient (or by the patient’s legally responsible party, if patient is a minor):

Truth in Lending Disclosure & Agreement (refer to sample at the end of this booklet).

Invisalign Informed Consent (included in each Invisalign submission box).

3rd Party Financing Agreement (provided by financial institution).

Automatic monthly payments authorization form as needed.

STEP 4 - COLLECT PAYMENT

Collect the agreed upon payment before proceeding to Step 5. Cash or personal check, a signed credit card slip and a signed 3rd Party agreement all qualify as proof of collected payment.

STEP 5 - Invisalign Required Records

Take all required Invisalign records as needed (photos, PVS impressions or scan, x-rays, etc.).

5


6 7

AFTER THE ORTHODONTIC CONSULTATION

After the patient has left the office, follow these steps to ensure that the orthodontic treatment is started immediately and services are paid in a timely manner.

STEP 1 - Submit Signed Agreements to the 3rd Party Financial Institution

Follow your 3rd Party Financial Institution’s requirements in order to submit and expedite the processing of the required payment. You may have to fax, mail, and/or e-mail the required information and signatures.

STEP 2 - Initiate Invisalign Submission Process

Submit all the necessary information online, prepare the submission box and ship via UPS. Record the tracking number and the date of shipment.

STEP 3 - Review and Approve the ClinCheck® Treatment Plan

To ensure that the orthodontic treatment is started and the services are paid in a timely manner, keep track of the cases ready to have their ClinCheck treatment plans reviewed and approved by the doctor.

STEP 4 - Deliver the Invisalign Aligners

As soon as the aligners are received, schedule an appointment with the patient to deliver the first Invisalign aligner set.

Important: Submit the insurance claim after the Invisalign aligners have been delivered.

STEP 5 - Submit the Insurance Claim

Once the first Invisalign aligner set has been delivered to the patient, the initial insurance claim can be submitted electronically or via paper form. (Refer to example orthodontic initial claim submissions at the end of this guide.)

On the initial insurance claim submission include all the following information to expedite processing, minimize the need for additional claims submissions, and avoid potential delays and/or denials:

1. Type of Transaction: Place an X in the box “Statement of Actual Services”

3. Primary Payer Information: Insurance Name & Address

12. – 17. Primary Subscriber Information

18. – 23. Patient Information

24. – 31. Record Of Services Provided

24. Procedure Date: Date Aligners inserted

29. Procedure Code: Adolescent (D8080), or Adult (D8090) dentition

30. Description: Comprehensive orthodontic treatment of the Adolescent/ Adult dentition

31. Fee. Be advised that if the treatment fee is adjusted due to a professional, cash or paid-in- full courtesy, the amount inserted in “31. Fee” of the ADA claim form should match the adjusted fee.

36. – 37. Authorizations Signatures

36. The patient, or legal guardian if the patient is a minor, must sign to authorize services to be rendered, assume financial responsibility within the limits of the insurance policy and consent to the insurance company’s use and disclosure of protected health information as needed in connection with the claim.

37. Assigning the Benefit. The insurance subscriber must sign to authorize the insurance company to pay any available orthodontic benefits directly to the doctor. Without a signature on this line, the payment may go to the insurance subscriber, who may not necessarily be the patient, and/ or financially responsible party. The orthodontic fee payment must then be collected in full from the financially responsible party, which can cause further delay in payment for services.

38. – 42. Ancillary Claim/Treatment Information

38. Place of Treatment: Provider’s Office

40. Is Treatment for Orthodontics? Yes

41. Date Appliances Placed: Date when first set of aligners were delivered to patient

42. Months of Treatment Remaining

48. – 58. Billing Doctor or Dental Entity


8 9

IMPORTANT TIPS

Submit Orthodontic procedures (D8XXX) separate from Dental procedures to avoid confusion and payment delays. Insurance companies separate their Dental and Orthodontic claim processing departments. Use a separate claim form.

Use the description associated with each CDT code by the ADA on the insurance claim submission form, any other description will cause delay or denials. For example, when you enter D8090 as the Procedure Code, enter “Comprehensive Adult Orthodontic Treatment”, no other commentary is required.

Call the insurance company to negotiate the Contract Fee if it is less than the orthodontic treatment fee.

Send the initial claim for orthodontic treatment after the aligners are delivered to patient. Then wait for the initial EOB (Explanation of benefits) for the confirmation of the insurance plan’s regular payment schedule set up and the claim submission requirements.

Orthodontic claims do not require clinical attachments or diagnostic casts.

Assigning the Benefits. It is recommended to assign the benefits so that insurance payments are made directly to the doctor/practice. If insurance payments are sent to the patient or insurance subscriber, additional follow up will be required to collect payments.

Submit the diagnostic records as Dental procedures. Diagnostic records (Panoramic x-ray, Cephalometric x-ray, Photographs and Study models) are often subject to frequency limitations and may or may not be processed as Orthodontic procedures. If processed as an Orthodontic procedure, they will reduce the available amount of the lifetime maximum orthodontic allowance.

Send the estimated patient balance for 3rd party financing. When working with 3rd party financing (Chase, Care Credit, etc.) it is recommended that only the estimated patient balance be financed, after deducting the estimated orthodontic insurance benefit from the total treatment fee, in order to minimize financing charges.

COORDINATION OF BENEFITS

If coordination of benefits is necessary, include all the Primary insurance carrier information, including deductible, coinsurance/co-pay, maximum and amount paid to date (if patient is continuing active treatment). Also include the Primary insurance provider Explanation of Benefits (EOB).

COMMON CDT ORTHODONTIC CODES*

COMPREHENSIVE ORTHODONTIC TREATMENT (Full Dentition/Both Arches)

D8080 Comprehensive orthodontic treatment of the adolescent dentition

D8090 Comprehensive orthodontic treatment of the adult dentition

LIMITED ORTHODONTIC TREATMENT (Partial Dentition/One or Both Arches)

D8030 Limited orthodontic treatment of the adolescent dentition

D8040 Limited orthodontic treatment of the adult dentition

OTHER ORTHODONTIC SERVICES AND ANCILLARY CODES

D8660 Pre-orthodontic treatment visit

D8670 Periodic orthodontic treatment visit (as part of contract)

D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)

D8690 Orthodontic treatment (alternative billing to a contract fee) services provided by doctor other than original treating doctor. May reflect a per-visit fee arrangement.

D8691 Repair of orthodontic appliance-does not include bracket and standard fixed orthodontic appliances. It does include functional appliances and palatal expanders.

D8692 Replacement of lost or broken retainer

D8693 Rebonding or recementing; and/or repair as required of fixed retainers

D8999 Unspecified orthodontic procedure, by report – used for procedures that are not adequately described by a code. When using it you must describe the procedure. This code indicates to the insurance representative that there is something unusual about the services rendered. Do not use this code. It may cause lengthy phone conversations with the insurance representatives to process and result in delayed or denied payment.

D9450 Case presentation visit with detailed and extensive treatment planning – established patient. Not performed on same day as evaluation.

D0330 Panoramic film

D0350 Oral/facial photographic images

D0470 Diagnostic casts


1110

Insurance Type: Indemnity Contracted Fee: NONE Orthodontic Coverage: Subscriber Age Limit: 99 yrs old Lifetime maximum coverage: $1,500 Percentage: 50% Deductible: $50

Waiting Period: None Standard or non-Duplication of benefits: Non-Duplication Pre-existing Conditions: No Billing schedule: Automatically / Quarterly

Here are the Payment Options that can be presented for this patient:

Option A: 3RD PARTY FINANCING (Chase, CareCredit, etc.)

No initial Payment. Low monthly payments.

Approved in minutes. Prepayments can be made anytime.

Option B: PAYMENT IN FULL Bookkeeping courtesy of 5% is given for payment in full at the start of treatment, resulting in a one- time payment of $ 4,750.00.

Option C: IN-OFFICE PAYMENT PLAN

In the event that a patient does not qualify for 3rd party financing, offer office payments as the last option:

An initial payment of $ 1,500.00 is due at the start of treatment, thereafter 8 monthly payments of $250.00 due the first of each month.

The monthly installments will be automatically withdrawn from your MasterCard, Visa or Discover credit account. Patient can choose a convenient day of the month.

Payment Arrangement Example 1

Treatment Fee Includes all aspects of the orthodontic treatment to be rendered in the practice: orthodontic appliances, routine and emergency visits, retainers after active treatment is completed and a year of retention follow-up. (Some practices also include all Diagnostic records)

Treatment Description Comprehensive adult orthodontic treatment (CDT D8090)

$5,000.00

$1,500.00

$3,500.00

11 months

Est. Insurance Payment

Est. Patient Portion

Est. Treatment Time

Payment Arrangement Example 2

Insurance Type: PPO Contracted Fee: $2,650 Orthodontic Coverage: Subscriber Age Limit: 99 yrs old Lifetime maximum coverage: $1,500 Percentage: 50%

Deductible: $50 Waiting Period: None Standard or non-Duplication of benefits: Non-Duplication Pre-existing Conditions: No Billing schedule: Automatically/ Quarterly



$2,650.00 (this is the PPO Contracted Fee)

$1,325.00

$1,325.00

12 months



Est. Treatment Time


Option A: 3RD PARTY FINANCING (Chase, CareCredit, etc.)



Option B: PAYMENT IN FULL

Bookkeeping courtesy of 5% is given for payment in full at the start of treatment, resulting in a one-time payment of $1,258.75.


Not recommended for this patient.

Given the cur rent insurance plan information (confirmed above), the presentation for an Invisalign Full case may be as follows: Given the cur rent insurance plan information (confirmed above), the presentation for an Invisalign Full case may be as follows:

Maximizing Orthodontic Insurance Benefits for Invisalign® Patients

12

Dental Claim Form

1. Type of Transaction (Mark all applicable boxes)

EPSDT/ Title XIX

HEADER INFORMATION

OTHER COVERAGE

Statement of Actual Services Request for Predetermination / Preauthorization

© 2006 American Dental Association

MISSING TEETH INFORMATION

34. (Place an 'X' on each missing tooth)

35. Remarks

J400 (Same as ADA Dental Claim Form – J401, J402, J403, J404)To Reorder call 1-800-947-4746or go online at www.adacatalog.org

1 2 3 4 5 6 7 8

32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

9 10 11 12 13 14 15 16 A B C D E F G H I J

T S R Q P O N M L K

Permanent Primary 32. Other Fee(s)

33.Total Fee

24. Procedure Date(MM/DD/CCYY)

25. Area of Oral Cavity

26.ToothSystem

27. Tooth Number(s)or Letter(s)

28. ToothSurface

29. ProcedureCode 30. Description 31. Fee

RECORD OF SERVICES PROVIDED

TREATING DENTIST AND TREATMENT LOCATION INFORMATIONBILLING DENTIST OR DENTAL ENTITY (Leave blank if dentist or dental entity is not submitting claim on behalf of the patient or insured/subscriber)

PATIENT INFORMATION18. Relationship to Policyholder/Subscriber in #12 Above 19. Student Status

Self Spouse Dependent Child Other

20. Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code

21. Date of Birth (MM/DD/CCYY) 23. Patient ID/Account # (Assigned by Dentist)22. Gender

M F

INSURANCE COMPANY/DENTAL BENEFITS PLAN INFORMATION3. Company/Plan Name, Address, City, State, Zip Code

5. Name of Policyholder/Subscriber in #4 (Last, First, Middle Initial, Suffix)

11. Other Insurance Company/Dental Benefit Plan Name, Address, City, State, Zip Code

4. Other Dental or Medical Coverage?

48. Name, Address, City, State, Zip Code

56. Address, City, State, Zip Code

54. NPI 55. License Number

49. NPI 50. License Number 51. SSN or TIN

Yes (Complete 5-11)No (Skip 5-11)

53. I hereby certify that the procedures as indicated by date are in progress (for procedures that require multiple visits) or have been completed.

Signed (Treating Dentist) DateX

2. Predetermination / Preauthorization Number

ANCILLARY CLAIM/TREATMENT INFORMATION

41. Date Appliance Placed (MM/DD/CCYY)

44. Date Prior Placement (MM/DD/CCYY)42. Months of Treatment Remaining

No Yes (Complete 44)

38. Place of Treatment

43. Replacement of Prosthesis?

39. Number of Enclosures (00 to 99)Radiograph(s) Oral Image(s) Model(s)


40. Is Treatment for Orthodontics?

Provider’s Office Hospital ECF Other

45. Treatment Resulting from

47. Auto Accident State46. Date of Accident (MM/DD/CCYY)

Occupational illness/ injury Auto accident Other accident

AUTHORIZATIONS36. I have been informed of the treatment plan and associated fees. I agree to be responsible for allcharges for dental services and materials not paid by my dental benefit plan, unless prohibited by law, or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted by law, I consent to your use and disclosure of my protected health information to carry out payment activities in connection with this claim.

DatePatient /Guardian signatureX

37. I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to the below named dentist or dental entity.

DateSubscriber signatureX

58. Additional Provider ID

FTS PTS

1

2

3

4

5

6

7

8

9

10

6. Date of Birth (MM/DD/CCYY) 8. Policyholder/Subscriber ID (SSN or ID#)7. Gender

M F

9. Plan/Group Number 10. Patient’ s Relationship to Person Named in #5

Self Spouse Dependent Other

POLICYHOLDER/SUBSCRIBER INFORMATION (For Insurance Company Named in #3)12. Policyholder/Subscriber Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code


M F

16. Plan/Group Number

(410)555-2415

x

The Insurance Company123 Moneyway BlvdSacramento, CA 94277

John Smith456 Pond WayAnaheim, CA 92803

02/30/1965 x 123-45-6789

05-56948

x


02/30/1965 x 123-45-6789

06/01/2011 D8090 Comprehensive adult orthodontic treatment 5,000.00

5,000.00

Signature on �le 06/01/2011


x

x 06/01/2011

11

Dr Bob Healthysmile567 RoadwayHillsboro, MN 54632

75342 95-96251234


(410)555-2415

75342

06/01/2011

Claim Form for Payment Arrangement Example 1Payment Arrangement Example 3

Insurance Type: HMO Contracted Fee: $2,650.00 Orthodontic Coverage: Subscriber Age Limits: 99 yrs old Lifetime maximum coverage: None Percentage: 0% Deductible: None

Waiting Period: None Standard or non-Duplication of benefits: Non-Duplication Pre-existing Conditions: No Billing schedule: None



$2,650.00 (this is the HMO Contracted Fee)

$0.00 This HMO does NOT pay for orthodontic treatment, therefore a claim form is not required.

$2,650.00

11 months



Est. Treatment Time


Option A: 3RD PARTY FINANCING (Chase, Care Credit …)



Option B: PAYMENT IN FULL

Bookkeeping courtesy of 5% is given for payment in full at the start of treatment, resulting in a one-time payment of $2,525.00.


In the event that a patient does not qualify for 3rd party financing, offer the following as the last option:

An initial payment of $ 1,490.00 is due at the start of treatment, thereafter 8 monthly payments of$145.00 due the first of each month.

Given the above current confirmed insurance plan information, the presentation for a Invisalign Full case may be as

Dental Claim Form


EPSDT/ Title XIX

HEADER INFORMATION

OTHER COVERAGE





35. Remarks


1 2 3 4 5 6 7 8

32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

9 10 11 12 13 14 15 16 A B C D E F G H I J

T S R Q P O N M L K


33.Total Fee



26.ToothSystem


28. ToothSurface








M F








49. NPI 50. License Number 51. SSN or TIN























FTS PTS

1

2

3

4

5

6

7

8

9

10


M F





M F


x


Jane Smith456 Pond WayAnaheim, CA 92803

7/26/1969 x 321-54-9876

05-56948

x

Jane Smith456 Pond WayAnaheim, CA 92803

7/26/1969 x 321-54-9876

06/01/2011 D8090 Comprehensive adult orthodontic treatment 2,650.00

2,650.00



x

x 06/01/2011

12

Bob Healthysmile567 RoadwayHillsboro, MN 54632

75342 95-96251234

Bob Healthysmile567 RoadwayHillsboro, MN 54632

(410) 555-2415 (410) 555-2415

75342

06/01/2011

Claim Form for Payment Arrangement Example 2

Dental Claim Form


EPSDT/ Title XIX

HEADER INFORMATION

OTHER COVERAGE





35. Remarks


1 2 3 4 5 6 7 8

32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

9 10 11 12 13 14 15 16 A B C D E F G H I J

T S R Q P O N M L K


33.Total Fee



26.ToothSystem


28. ToothSurface








M F








49. NPI

( ) – ( ) –

50. License Number 51. SSN or TIN























FTS PTS

1

2

3

4

5

6

7

8

9

10


M F





M F


x



02/30/1965 x 123-45-6789

05-56948

x


02/30/1965 x 123-45-6789

07/01/2011 D8690 Orthodontic treatment $250.00

$750.00



x

x 06/01/2011

8


75342 95-96251234410


555 2415 555 2415410

75342

09/01/2011

08/01/2011 D8690 Orthodontic treatment $250.00 09/01/2011 D8690 Orthodontic treatment $250.00

Example Claim Form for Continuing Ortho Visits

Dental Claim Form


EPSDT/ Title XIX

HEADER INFORMATION

OTHER COVERAGE





35. Remarks


1 2 3 4 5 6 7 8

32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

9 10 11 12 13 14 15 16 A B C D E F G H I J

T S R Q P O N M L K


33.Total Fee



26.ToothSystem


28. ToothSurface








M F








49. NPI

( ) – ( ) –

50. License Number 51. SSN or TIN























FTS PTS

1

2

3

4

5

6

7

8

9

10


M F





M F


x



02/30/1965 x 123-45-6789

05-56948

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02/30/1965 x 123-45-6789

07/01/2012 D8680 Orthodontic Retention $750.00

$750.00



x

x 06/01/2011

0


75342 95-96251234410


555 2415 555 2415410

75342

07/01/2012

Example Claim Form for Retention

Federal Truth in Lending Statement For Professional Services

Patient: Responsible Party: Relationship to Patient:

Professional Services Description of Services: Orthodontic Treatment

Estimated Treatment Time: Months

Retention: Months

Miscellaneous: Total Fee for Professional Services* $ 1) Other Charges/Credit: $ 2) Less Estimated Insurance Coverage $ 3) Estimated Patient Portion $ 4) Less Initial Payment $ 5) Unpaid Balance $

Payable starting / / at $ per month for months.

Additional Terms and Conditions a) “Total Fee for Professional Services” includes : The Professional Services as stated above, as well as orthodontic

aligners, routine and emergency visits for the Estimated Treatment Time. b) Should treatment extend beyond the estimated treatment time, for any reason, additional fees will be charged. c) There will be an additional charge for loose, broken or lost aligners, and for x-rays, photographs and study models. d) Any overdue, outstanding balance will be subject to a Late Charge of $ per month. e) I understand in the event of transferring treatment to another dental office there will be a $ charge for the

duplication of records, payable at the time of the request. f) I understand there will be a check return charge of $ . g) I understand there will be a $ charge for appointments missed without a 48 hour notice.

I understand that this office reserves the right to report to the major credit reporting agencies a ny delinquent or bad accounts over 90 days in arrears. I also understand that I, rather than my insurance company, am responsible for all the fees relating to this treatment, including any balances unpaid by my insurance company.

I have read and understand this agreement, and will agree to the terms and conditions thereof. I give consent for the treating dentist to do whatever procedures he/she deems necessary to achieve the objectives and benefit s from this indicated treatment for my child/self. Date Signature of Patient/ Financially Responsible Party Date Signature of Doctor/ Authorized Associate

* Must be paid in full before treatment is completed. The initial payment must be received in our office before the first treatment appointment. The monthly fee paid does not correlate to the treatment received in any given month. If for any reason there is any remaining balance not paid by Insurance, full payment is the responsibility of the patient.

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APPOINTMENT DATE:

STEP 1Get all this

Info

STEP 3Review

STEP 2Call

insurance company &

verify Ortho

benefits

STEP 1Exam & TX

Presentation

Name:

Date of Birth:

Male Female

Address:

Responsible Party

Today’s Date: Scheduled By:

Cell Phone.

Evening Phone.

E-mail Address:

Name:

Date of Birth:

Employer

ID or SS.

Insurance group.

Name of Carrier:

Phone:

Type: Indemnity PPO HMO

Address:

Relationship to Patient:

Covered: Subscriber Spouse Child

Date of Birth:

Percentage: %

Waiting Period: Months

Billing Schedule : Auto Monthly Quarterly Semi-annually

Payment Schedule : Monthly Quarterly Semi-annually

Age Limit:

Insurance Representative’s Name: Called - Initial & Date:

Review important information with the doctor and team before starting the consultation (health history, treatment concerns, financial considerations, insurance limitations, etc.

CDT CODE* and Treatment Description : *Additional codes can be found in GuideD8080 Comprehensive orthodontic treatment of the Adolescent dentitionD8090 Comprehensive orthodontic treatment of the Adult dentitionD8030 Limited orthodontic treatment of the Adolescent dentitionD8040 Limited orthodontic treatment of the Adult dentition

Remaining Lifetime Benefit: $

Deductible: $

Dual Coverage: Standard Non-Duplication

Chief Concern:

PATIENT

SUBSCRIBER

INSURANCE

INSURANCE GUIDE SUMMARY

BEFORE THE ORTHODONTIC CONSULTATION

DURING THE ORTHODONTIC CONSULTATION

CONSULTATION APPOINTMENT

ORTHO COVERAGE

CONTRACT FEE: $

YES NO

TIME:

Length of Invisalign Treatment Invisalign Treatment Fee: $

STEP 2

STEP 3

STEP 5

STEP 1

STEP 3

STEP 4

STEP 4PAYMENT

STEP 2Submit to Invisalign

STEP 5Claim

Submission

Initial payment: $

Credit Card:

Exp date:

Posted - Initial & Date:

Monthly payment: $ Due on the___________________ of each month

Card holder name:

CV Code:

Online form - Initial & Date:

Box shipped - Initial & Date:

In box: Impressions Form Panorex Photos

Fill out all the following information in the ADA claim form:

1. Type of Transaction: Type a“X” on the box ”Statement of Actual Services”3. Primary Payer Information: Insert the insurance company’s name & address12. - 17. Primary Subscriber Information: Insert the insurances policy holder’s information18. - 23. Patient Information: Insert the patient’s information24. Procedure Date: Insert the date the Invisalign aligners were delivered to patient29. Procedure Code: Insert the CDT code. Eg. D8090 for Adult dentition30. Description: Insert the treatment description, Eg. Comprehensive orthodontic treatment of the Adult dentition31. Fee: Insert the total treatment fee, after all courtesies have been adjusted.36. Signature: Insert signature of the patient or if the patient is a minor, the legal guardian37. Signature: Insert the subscriber’s signature38. Place to Treatment: Type a “X” on the box “Provider’s Office40. Is Treatment for Orthodontics? Type a ”X” on the box “Yes”41. Date Appliances Placed: Insert the date when aligners were delivered to patient. Must match the entry on 24.42. Months of Treatment Remaining: Insert the estimated length of treatment48. - 58. Billing Dentist or Dental Entity: Insert the doctor’s information53. Signature: Insert the treating dentist’s signature

Present payment arrangements to patient and /or financially responsible party

Submit Signed Agreements to the 3rd Party Financial Institution - Initial & Date:____________________

ClinCheck® Approved - Initial & Date:____________________

Aligners Delivered - Date:____________________

Submit Insurance claim after Aligners have been delivered.

COLLECT PAYMENT (3rd Party Financing agreement signed, cash, check, or credit card slip signed)

Review contract and informed consents with patient and/or responsible party

Contact signed - Initial & Date: Consent signed - Initial & Date:

Invisalign Required Records Taken - Initial & Date:__________________________________

Impressions Taken - Initial & Date:________________________________________________

Records - Initial & Date:

TR#:

Invisalign RECORDS

INSURANCE CLAIM SUBMISSION

Invisalign RECORDS SUBMISSION

PAYMENT ARRANGEMENTS

AFTER THE ORTHODONTIC CONSULTATION

INSURANCE INITIAL CLAIM SENT - INITIAL & DATE:

INSURANCE EOB PAYMENT RECEIVED & POSTED - INITIAL & DATE:

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M20179, REV 1 ©Align Technology, Inc. All rights reserved.

Align Technology, Inc.

2560 Orchard ParkwaySan Jose, CA 95131www.invisalign.com

Documents

ORTHODONTIC INSURANCE - Cloud Object Storage · PDF fileorthodontic insurance coverage before the patient orthodontic consultation, treatment and fee presentation. STEP 1 - Get patient