Secondary Claim Billing for Orthodontia

October 22, 2013

MaineCare reimburses a one-time, lump sum payment on orthodontic codes D8070, D8080, and D8090 while commercial insurance plans may pay more frequently throughout a patient’s course of treatment. This has resulted in multiple claims adjustments and difficulty in matching primary carrier Explanation of Benefits (EOBs) to MaineCare claims for secondary payment determination.

To improve claims processing for these services when there is a primary payer, effective with Prior Authorization (PA) requests received October 22, 2013, please submit claims as follows:

  1. Prior Authorization (PA) request for D8070, D8080, D8090: Submit a copy of the primary dental insurance carrier’s predetermination letter with the PA request. The PA will be issued for all approved dental code(s) supplied on the predetermination letter for the difference between the MaineCare allowance and the primary insurance predetermination benefit amount.

  2. Claim submission for D8070, D8080, D8090: Claims for D8070, D8080 and D8090 should be submitted as paper claims to ensure accurate payment calculation. Include a copy of the Explanation of Benefits (EOB) and the predetermination letter from the member’s primary dental insurance carrier but do not mark any Third Party Liability (TPL) payment on the claim. The claims will pend for review and will be priced according to the amount authorized by MaineCare.

  3. If you are billing for a dental code in addition to D8070, D8080, or D8090, submit that code on a separate claim with the TPL payment included. A claim with one of the three (3) orthodontic codes and an additional code will be rejected with a Returned to Provider Letter (RTP).

If the amount that the primary dental insurance carrier pays toward the orthodontia changes at any time during the member’s course of treatment, you must initiate updates to both the PA and claims.