Find an Orthodontist Near You

Insurance Filing Protocol for Orthodontic Coverage for Children with CLP Through SB630

posted on 2-23-17

California alone has more than one million uninsured children, according to Kaiser Family State Health Facts (www.statehealthfacts.org). Although the legislation does not address dental and oral health, we understand these needs as integral to overall health and as practitioners we must involve ourselves in furthering discussion and shaping policy that will address the needs of underserved patients. In a 2006 white paper entitled “Access to Orthodontic Care,” the American Association of Orthodontists notes, “With respect to orthodontic care and government resources, we believe that financial support should be directed to those patients where the need is the greatest, such as young people with debilitating malocclusion, cleft palate and other craniofacial deformities. “According to this same paper (available at http://www.aaomembers.org/Resources/Publications/Access-to-Care-White-Paper.cfm), 87% of practicing AAO members provide free or discounted treatment for those in need. Every day, the challenge of securing orthodontic treatment for the most needy of young patients confronts craniofacial clinics throughout the western states. Mathematically, it shouldn’t at least not in California.

 

Of the approximately 37.7 million California residents, roughly 26%, or nearly ten million, are children under 18, according to Kaiser Family State Facts. Cleft lip and/or cleft palate constitute the most common congenital malformation of the head and neck with a frequency of 1 in 600 throughout the U.S. This suggests that approximately 16,667 children in California have cleft lip and/or palate, and only a percent-age of them would need orthodontic care at any given time. According to the California Association of Orthodontists, the state has approximately 1,000 active orthodontists. Additionally, five orthodontic schools in California each take at least five orthodontic residents each year. If about 40% of California children with cleft lip and palate were in need of orthodontic treatment at a given time, it would mean approximately 6,600 children. That comes out to a practitioner-to-patient ratio of 1:6; one would assume access to care would not be particularly challenging with those numbers.

 

But experience dictates otherwise. In fact, many of the neediest children with cleft and craniofacial conditions cannot secure local orthodontic care. Indeed, we hear of patients who postpone treatment altogether. At our clinic at UCSF, we always try to arrange local treatment first, since the most needy and underserved also face financial hardships exacerbated by traveling long distances and missing work for frequent treatment visits. Our craniofacial diagnostic clinic sees patients from more than 25 Northern California counties. The UCSF orthodontic program accepts Denti-Cal patients and is currently seeing more and more young patients making a half-day drive with a family member to and from the clinic for monthly appointments simply because they are unable to find local treating orthodontists. We treat both publicly insured patients in counties where no orthodontists accept Denti-Cal patients, and privately insured patients through Senate Bill 630.

 

The purpose of this article is to assist the orthodontist and parent in obtaining authorization for orthodontic treatment of a child with cleft lip and palate. Orthodontic treatment for a child with a cleft lip and palate or cleft palate is medically necessary and therefore should be covered through their medical insurance. Senate Bill 630, effective July 1, 2010 defines reconstructive surgery to include medically necessary dental or orthodontic services that are an integral part of reconstructive surgery for cleft palate procedures, except as specified.  We suggest accompanying requests to the insurance company with the following. The treating orthodontist or parent may submit this.

1)  letter from clinic / orthodontist noting medical necessity
2)  copy of photos and films;
3)  treatment plan – course of treatment; estimate of cost;
4)  copy of SB 630.

We also suggest that you document all contacts with your insurer.  This means maintaining copies of all correspondence, noting a log of all phone calls (date, time and person with whom you spoke), and summarizing the outcome of the correspondence or call.  This will be helpful should you need to appeal.  Insurance companies have been apprised of this clarification in coverage, but as this is a change in how things have been in the past, we anticipate there may be confusion, delays, and perhaps denials

It may be useful to maintain records of denials and approvals, which can help assist other families as well as further any legislative efforts and clarifications necessary.

Here are some helpful tips for you to bill the child’s medical insurance for coverage. We have been successfully billing medical insurances including Blue Shield, Blue Cross, Kaiser and other plans. They pay in full at the contracted rate (between 60-80%) at the start of treatment.

 

HMO Insurance

  1. Obtain the patient’s most recent craniofacial report.
  2. You will need a referral from the patient’s primary care physician to your office.  If the primary care is asking what the referral is for you can give them ICD9 code listed on the craniofacial report.
  3. After you receive the referral from the primary care physician, you are going to send in for pre-authorization.  The following items will be needed with the pre-authorization:

 

  • Pre-authorization request (Do not need to include, down payment and monthly payment amount, or length of treatment.) On your pre-authorization request, under the comments field enter the diagnosis code and name.
  • Craniofacial report
  • Referral from Primary Care
  • Copy of SB630
  • Sometimes they will ask for a copy of the pano/ceph
  1. After you receive the pre-authorization, sometimes the insurance company will set up a single case agreement or LOA (Letter of Agreement) because you are out of network.  It’s basically a contract stating what percent the insurance company is willing to pay for billed charges.  Whatever percentage is negotiated, you are not allowed to ask the patient for the difference.
  2. Start billing for services. Again you do not need to put down the down payment amount and monthly payment amount. Same as the pre-authorization, enter the ICD9 code and name under the comments field.  Also, enter the pre-auth # on the claim form.  When submitting the claim make sure you attach the following:
  • Craniofacial report
  • Pre-authorization
  • Copy of SB630
  • Copy of LOA


PPO Insurance

 

  1. Obtain the patient’s most recent craniofacial report.
  2.  The following items will be needed with the pre-authorization:
  • Pre-authorization request (Do not need to include, down payment and monthly payment amount, or length of treatment.) On your pre-authorization request, under the comments field enter the diagnosis code and name.
  • Craniofacial report
  • Copy of SB630
  • Sometimes they will ask for a copy of the pano/ceph
  1. After you receive the pre-authorization, sometimes the insurance company will set up a single case agreement or LOA (Letter of Agreement) because you are out of network.  It’s basically a contract stating what percent the insurance company is willing to pay for billed charges.  Whatever percentage is negotiated, you are not allowed to ask the patient for the difference.
  2. Start billing for services. Again you do not need to put down the down payment amount and monthly payment amount. Same as the pre-authorization, enter the ICD9 code and name under the comments field.  Also, enter the pre-auth # on the claim form.  When submitting the claim make sure you attach the following:

 

  • Craniofacial report
  • Pre-authorization
  • Copy of SB630

The Types of insurance plans that are excluded from the senate bill:

  • ERISA Health Plans
  • Federal Government Plans

Information, Assistance and Appeals

1)    California Department of Insurance –The California Department of Insurance (CDI) oversees many indemnity policies and many PPO’s (Preferred Provider Option networks) in California.  For further information or for help with insurance problems with these plans, you may contact the CDI at 1-800-927-HELP (4357) or explore their website at:  www.insurance.ca.gov.

 

2)    California Department of Managed Health Care – The Department of Managed Health Care (DMHC) oversees all HMO’s (Health Maintenance Organizations) and some PPO’s in California. For further information or for help with insurance problems with these plans, you may contact the DMHC at 1-888-466-2219 or explore their website at: www.dmhc.ca.gov.   The DMHC’s HELP line can assist you in the process of appealing a denial and requesting an Independent Medical Review (IMR).

 

3)    Self-Funded Health Benefit Plans – these are plans for which the employer sets aside funds to pay the health coverage claims. This type of plan is governed by the Employee Retirement Income Security Act of 1974 (ERISA). These plans are governed by federal law, overriding state laws.  The laws that apply and the appeal process are different; for further information or assistance in the process of appeals, contact the Department of Labor:  Northern California: 1-866-444-3272; Southern California: 1-866-275-7922.  The website can be located through the Department of Labor Employee Benefits Security Administration at: www.dol.gov/ebsa. 

Additional information regarding insurance and the appeal process is available on the website of Cleft Advocate at www.cleftadvocate.org/insurance.html. 

Comments

  • Sarah Nelson

    Can someone please explain to me why my daughter’s orthodontist is refusing to file with our medical insurance for cleft palate care (braces) to prepare for her next surgery when she fully knows that our medical insurance covers her? Why? Why the refusal of medical and the demand to only file with dental insurance fully knowing that dental doesn’t cover it?

    Actually, this 8s the second person refusing to file with our medical. First it was the oral surgeon who demanded over $20,000 cash up front whom we replaced, and now the orthodontist. Someone please tell me what is going on. We are running out of time to do the next phase of treatment.

Leave a Comment

Your email address will not be published. Required fields are marked *