The initial payment is based on the total treatment fee submitted by the orthodontist. A fixed amount is used to calculate the initial benefit, and the remaining eligible orthodontic benefit is then distributed over the rest of the treatment period.
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.