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Orthodontic Benefits

HealthChoice covers orthodontic services for members under the age of 19; and for members ages 19 and older with temporomandibular joint dysfunction. Certification is required through the HealthChoice Health Care Management Unit for members aged 19 and older. For questions about certification, call HCMU at 405-717-8879 or toll-free 800-543-6044, ext. 8879. TTY users call 711. 

HealthChoice pays 50% of allowable fees, and there is no calendar year deductible or lifetime maximum benefit. A 12-month waiting period applies to all orthodontic benefits. The 12-month waiting period will be waived for services required for the treatment of TMD (regardless of age) but certification is required for treatment of TMD and the 12-month waiting period is waived as part of that process. 

Providers must submit one claim for the entire inclusive orthodontic course of treatment. The claim must include the banding date and the length of treatment in months. The payment for the first month of treatment is half the orthodontic benefit; the balance is payable in monthly installments over the remaining length of treatment so long as the patient remains eligible. 

This only applies to comprehensive orthodontic ADA codes. 

For questions about orthodontic benefits, call the claims administrator toll-free at 800-323-4314. TTY users call 711.  

Orthodontic benefits can be complicated, but to simplify the benefit for your ease of use, the chart below lists what is covered, not covered and what is all-inclusive.

  Description Benefit Clarification
D8010 Limited orthodontic treatment of the primary dentition. Covered and can bill separately.
D8020 Limited orthodontic treatment of the transitional dentition. Covered and can bill separately.
D8030 Limited orthodontic treatment of the adolescent dentition. Covered and can bill separately.
D8040 Limited orthodontic treatment of the adult dentition. Covered and can bill separately.
D8050 Interceptive orthodontic treatment of the primary dentition. Covered and can bill separately.
D8060 Interceptive orthodontic treatment of the transitional dentition. Covered and can bill separately.
D8070 Comprehensive orthodontic treatment of the transitional dentition. Covered and all-inclusive.
D8080 Comprehensive orthodontic treatment of the adolescent dentition. Covered and all-inclusive.
D8090 Comprehensive orthodontic treatment of the adult dentition. Covered and all-inclusive.
D8210 Removable appliance therapy. Covered and can bill separately.
D8220 Fixed appliance therapy. Covered and can bill separately.
D8660 Pre-orthodontic treatment visit. Covered and can bill separately.
D8670 Periodic orthodontic treatment visit. Not covered.
D8680 Orthodontic retention. Not covered.
D8690 Orthodontic treatment. Covered and can bill separately.
D8691 Repair of orthodontic appliance. Covered and can bill separately.
D8692 Replacement of lost or broken retainer. Covered and can bill separately.
D8693 Re-bonding or re-cementing; and/or repair, of fixed retainers. Covered and can bill separately.
D8999 Unspecified orthodontic procedure, by report. Each claim will be reviewed for coverage. Provide written description of dental necessity.

Note: All-inclusive includes retainer, appliances, etc. Not covered: This is the member’s responsibility.

4166

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