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HealthChoice orthodontic benefit

Friday, April 17, 2020

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.

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.

For questions about certification, call HCMU at 405-717-8879 or toll-free 800-543-6044, ext. 8879. TTY users call 711.

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