Orthodontic Insurance Benefits

This week, Amy Morgan dives into the details of orthodontic insurance benefits, shedding light on why some patients may be referred to other orthodontists. She explains the scoring system used to determine eligibility for orthodontic coverage under various insurance plans, and she discusses the options available to patients who may not meet the scoring threshold while emphasizing the flexibility for those wanting to continue their orthodontic care with PDAO. 

First, we want to clarify that if we are having to refer you or your child to another location, this is because PDAO as a practice has reached our capacity for your insurance. Meaning, as far as our orthodontic department goes, we no longer have the room or the availability to accept any other patients identified under your insurance plan. As a result, because we feel strongly that kids should be able to utilize their dental insurance plan and we want you to get the most out of your benefits, we will then refer you to another orthodontist office in our surrounding area that we believe provides excellent care.

Now, when it comes to insurance, whether you’re under Delta Dental, Smiles, MCNA, or the ARKids Plan, the orthodontic benefits are very similar and the system with which you are approved or denied is the same, however Arkansas state insurances only cover orthodontics if it’s considered medically necessary. And this is determined with a scoring system that takes into account things like crowding, crossbites, or missing teeth. 

To break it down further, if we have referred you to another practice, once you make contact with them, they will schedule a consultation where they will most likely take some x-rays and photos and then their orthodontist will do an examination to document any crowding, crossbites, missing teeth, etc. What is revealed in this examination will determine you or your child’s ranking on the scoring system and you have to meet a certain threshold in order for them to then send you or your child’s treatment plan in for approval. If you meet the threshold, the orthodontist will send in your information for approval and they will contact you to let you know if you were approved or denied.

If you do not meet the scoring threshold, most likely what will happen is that the referred practice will talk with you about what treatment they think is necessary and present you with a treatment plan and what that treatment plan would cost if you chose to receive that care from their orthodontist. If you ultimately decide to pay out-of-pocket for the referred office’s treatment plan, that choice is completely up to you! However, if you decide that you’d like to decline their treatment plan and continue with collaborative care at PDAO where you have all your dental checkups, fillings, etc., then let us know and we’d love to schedule a consultation with you and present a treatment plan from one of our in-house orthodontists. 

We want to reiterate that just because we are referring you to another practice in order to have the scoring system and use your insurance benefits, DOES NOT mean you cannot return to PDAO. The biggest reason we are referring you to another office is because we want you to get the absolute most out of the dental benefits that are provided for you or your child! 

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