This information sheet is intended to address Frequently Asked Questions (FAQs) about orthodontic item numbers.
Practitioners can itemise orthodontic treatment in two ways:
- As a complete course of orthodontic treatment (using item number 881) or
- By itemising according to the individual components of treatment provided, as occurs in general dental treatment (e.g. using item number 831 or 825 or 833 as the case may be).
It can be helpful to understand the business rules of individual major Private Health Insurers (PHIs), to assist your patients access their entitlements. Typically, policies which cover orthodontic treatment have both annual limits and lifetime limits.
Private Health Insurers
Patients who have ancillary cover with a PHI may be entitled to rebates for orthodontic treatment. This depends on their particular policy and their level of cover. It is recommended that practitioners encourage their patients to enquire about the rules of their particular policy with their PHI when discussing informed financial consent.
General dentists can use the same item numbers as orthodontists, according to the treatment they provide. All of the major PHIs (Medibank Private, Bupa, HCF, nib) pay rebates on orthodontic treatment provided by general dentists as well as registered specialists. Some funds pay higher rebates for treatment provided by specialists.
Some PHIs do not require the submission of treatment plans in order for their members to access orthodontic benefits while others do. Regardless of the PHI, Advisory Services recommends the submission of a treatment plan.
Orthodontic Accounts and PHIs
Orthodontic claims for courses of treatment are unusual because they do not follow the rules set out in the Australian Schedule of Dental Services and Glossary, due to sequential billing. In order to allow your patients to access their entitlements from their PHI, the date of service needs to be changed to match the date that fees are paid. Submission of a treatment plan will assist the processing of claims. Advisory Services recommends processing these claims manually rather than through HICAPS or similar. The patient can then submit their account to their PHI and receive benefits until they reach their annual limit, or lifetime limit, whichever comes first.
Important Points to Note
- Advisory Services recommends you accurately itemise according to the treatment provided.
- Practitioners cannot be aware of the maximum benefit payable on individual item numbers. If you allocate a lower dollar amount than the maximum rebate to a particular item, this will cap the amount your patient can receive to that lower figure. In order to ensure that your patient can access their appropriate entitlements, Advisory Services recommend that you use item number 881 which is all inclusive for the course of treatment.
- For practitioners who have commenced itemising treatment as individual components, Advisory Services recommends that this method be maintained until that patient’s treatment is complete.
- Please be aware that some policies place limits that extend over three calendar or financial years. If your treatment does not extend to this time frame, your patients will not be entitled to access their lifetime limits and this is simply a function of the PHI product selected by the patient.
Disclaimer:Â This is one of a series of Advisory Services information sheets created by ADA NSW. They are intended as general guides that highlight key pieces of information frequently requested. They do not set out to provide comprehensive information about a topic and they are not legal advice. Please be mindful that information provided in these resources can change after the publication date.
