Frequently Asked Questions

Orthodontic FAQs - Dentists

• How are orthodontic services paid?

  Orthodontic benefits will be paid monthly throughout the course of treatment. The method used to calculate the initial payment and subsequent monthly payments has recently been updated. These updates are intended to provide a more predictable payment approach for banded orthodontic cases while continuing to distribute benefits over the duration of treatment. The initial amount considered for payment is now based on the total treatment fee, rather than a percentage of the total treatment fee.  Here’s an example of how orthodontic services will be paid moving forward. 

  Calculation	How is it Calculated?	Example
  Start with the total fee for treatment.	Total orthodontic treatment fee submitted with the claim.	$5,000
  The amount considered for the initial payment is determined by the total treatment cost. Because the total case fee is greater than $5,000, the initial amount considered is $1,000.	If the total treatment fee is less than $1,000, $500 is considered. If the total treatment fee is $1,000 or greater, $1,000 is considered.	$1,000
  Calculate the initial benefit payment based on the member's 50% coinsurance to get the initial payment from Delta Dental.	Initial amount considered x applicable coinsurance/copay	$1,000 x 50% = $500
  The initial payment is subtracted from the lifetime plan maximum to determine the remaining eligible benefit, which will be distributed across the remaining treatment months.	Lifetime maximum - initial payment = remaining eligible benefit	$2,000 - $500 = $1,500
  Monthly payment considered is determined by dividing the remaining benefit (from the previous step) by the amount of remaining months of treatment. The initial payment is the total for the first month of treatment, so in this case there are 23 months left.	Remaining eligible benefit + remaining monthly payments = monthly payment amount	$1,500 ÷ 23 = $65.22

• How were orthodontic services paid previously?

  Previously, Delta Dental of Illinois paid 25% of the total treatment fee upfront, subject to applicable coinsurance. The remaining treatment cost was divided across the treatment period and paid monthly at the applicable coinsurance level.

• How will the recent calculation change impact payments for treatments in progress?

  Patients already in active orthodontic treatment may see changes to their monthly payments moving forward as remaining benefits will be recalculated using the revised orthodontic payment methodology. This may result in higher or lower monthly payments going forward, but the total orthodontic benefit paid will not exceed the member's available orthodontic maximum.

• How is the initial orthodontic payment determined?

  To determine the initial payment, a fixed amount will be applied based on the total treatment fee submitted with the claim. 

  • For orthodontic treatment with a total treatment fee less than $1,000: $500 will be considered at the applicable coinsurance/copay.

  • For orthodontic treatment with a total treatment fee of $1,000 or greater: $1,000 will be considered at the applicable coinsurance/copay.

  For example, a member receives orthodontic treatment with a total treatment fee of $5,000 and has a plan that pays 50% of covered orthodontic services. Because the total treatment fee is greater than $1,000, the initial payment is based on $1,000.

  • Initial amount considered: $1,000

  • Plan pays 50%: $500 initial payment

  ​The remaining eligible orthodontic benefit is then distributed across the remaining treatment months according to the member's plan benefits and orthodontic maximums.

• How are monthly payments calculated?

  After the initial payment is made, the remaining eligible orthodontic benefit is distributed across the remaining treatment months. Monthly payments are based on the member's orthodontic benefits, including applicable coinsurance, remaining orthodontic maximum, the initial payment amount and the number of treatment months remaining.

• Are treatment plans required?

  Treatment plans remain required. Payments continue automatically after the initial claim and remain subject to eligibility, plan provisions, orthodontic maximums, and applicable limitations.