Understanding Your Orthodontic Insurance

Direct Billing means you don’t pay thousands upfront. We handle the paperwork, submit all insurance claims on your behalf, and help to maximize your coverage. The following guide explains how your insurer pays us, so you always know what to expect.

Orthodontic insurance works differently from regular dental claims, so we’ve broken down the steps to help you understand the statements you will see from your insurance, and how your plan pays us. 

How Direct Billing Helps

• Lower upfront cost: most patients avoid paying several thousand dollars at the start of treatment.

• We handle the paperwork: you don’t have to submit claims or track payouts.

• You receive the full benefit available: our team works to collect every eligible dollar.

• Flexible payment plans: your payments are based on your needs, not your insurer’s timeline.

What We Send to Your Insurer

When we bill an insurance company for orthodontic treatment, we will first send them a Treatment Plan that informs the insurance company that treatment will be starting; what the total treatment fee is; and how long we estimate treatment will take. This often leads your insurance company to send out a Predetermination, which you might receive or see in your insurance account online (we do not need a copy of this form). Insurance payments are collected in two stages: first, we submit an Initial Claim at the start of treatment, and then we send Monthly Claim forms on the first of each month until your plan’s orthodontic benefits are fully used.

How the Initial Claim Works

When do we submit the Initial Claim? The Initial Claim is submitted on the day that the Financial Agreement is signed.

How much is submitted on the Initial Claim? Depending on the insurance company, up to 40% of the total treatment fee will be included within the initial claim.

For example, if the treatment fee is $7,000, and the insurance company requests a 35% Initial Claim amount: 35% of $7,000 is $2,450, and this is the amount that will be submitted on the Initial Claim.

Does my plan pay the full Initial Claim amount to Simply Ortho? It all depends on your coverage! What we are paid depends on your plan’s maximum allowed amount and coverage percentage for orthodontics.

Using the above example: If your plan covers 50% of orthodontic treatment, and the Initial Claim amount is $2,450, the insurance plan will pay $1,225 (50% of $2,450).

Will I be charged whatever my plan doesn’t pay on the Initial Claim? No, your personal payment amounts and timing are separate from the Insurance claim schedule. However, if your plan ends before expected benefits are paid, or if benefits are exhausted, any unpaid portion of your treatment will shift to you.

What Monthly Claims Look Like

When do we submit the Monthly Claims? Monthly claims are submitted on the 1st of each month, starting the month after the Initial Claim is sent. We do not send claim forms based on your appointment dates with Simply Orthodontics.

For Example: For treatment that started in August, the first monthly claim sent would be for September 1st, with a new monthly claim form being sent on the 1st of each month following.

How much is submitted on each Monthly Claim? The Monthly Claim amount will depend on the treatment fee, Initial Claim amount and the estimated treatment time:

(Total Treatment Fee  –  Initial Claim Amount) / Estimated Treatment Time = Monthly Claim Amount

For Example, using the example from the Initial Claim section, with the treatment fee of $7,000 and Initial Claim of $2,450: Let’s say that in this scenario, the estimated time for treatment is 15 months. The equation to determine the Monthly Claim amount would go like this:

$7,000 - $2,450 = $4,550 treatment fee not yet claimed
$4,550 / 15 = $303.33 per month to claim
Monthly Claim amount = $303.33

How Much Your Plan Will Pay

Every plan is different, and what we are paid each month depends on the orthodontic coverage maximum for the plan.

Using the above example: If orthodontic coverage is 50%, and the monthly claim amount is $303.33, our office will receive payment of $151.67 (50% of $303.33), up to the maximum coverage amount.

How many monthly claims do we submit? Most insurance plans have a maximum orthodontic benefit, regardless of the percentage of coverage. We submit monthly claims until either your plan’s maximum is reached or the full number of treatment months has been claimed, whichever comes first.

Picking up on the above example:

• Treatment Fee of $7,000

• Estimated treatment time of 15 months

• Coverage of 50% coverage (to a maximum of $3,000)

Having received a $1,225 Initial Claim payment, we know we can collect $1,775 more in monthly payments before the plan’s maximum of $3,000 is reached.

$1,775 / $151.67 = 11.7 monthly claim forms (we send 12 Monthly Claim forms)

We expect 11 months of insurer payments for $151.67 per month, and on the 12th month a payment of $106.67.

The total of these monthly payments ($1,775) plus the insurer’s initial payment ($1,225) adds up to the maximum coverage amount of $3,000.

What Happens if Your Plan Terminates

Will I be charged the amount my plan doesn’t cover from each Monthly Claim? No, when we calculate how much we can get from your plan and how long it will take to pay out, we account for the amount we are being paid, not the amount we are putting on the claim forms. However, if the plan is terminated before we can collect the full amount from your plan, or the benefit was previously exhausted and is less than expected, or a dependent becomes ineligible due to age restrictions, any outstanding balances will need to be collected from you.

Why Your Payments Don’t Match Your Insurance Claims

Your monthly payments to our office are independent of how and when your insurance pays us. We create a payment plan that fits your budget, not one based on your insurer’s timing.  Your insurance typically pays a larger amount up front than you will. Sometimes the amounts may look similar, but that’s just coincidence.

A Note About Alberta Blue Cross + Health Spending Accounts (HSA)

At times the unpaid amount from a claim submitted to Alberta Blue Cross will be automatically paid by your Health Spending Account, although our team does not ask Alberta Blue Cross to do this. We are not authorized to change this setting on your account; if you’d prefer this not occur, you can ask Blue Cross to remove this automatic feature.

When Insurance Situations Get More Complex

Orthodontic insurance can be straightforward, but there are situations where things get a little more complex. For example:

• Multiple insurance plans such as plans from two parents, step parents or a secondary plan through your employer; these may share benefits in specific ways.

• Plans with unusual rules such as yearly orthodontic maximums, age cutoffs, or health spending account top-ups.

• Changes in coverage during treatment (policy renewals, job changes, or plan upgrades) which can affect future claim amounts.

These may take a bit more navigation. No matter the situation, you won’t be left to sort it out alone. Our team works directly with insurers, helping you to understand your benefits, helping you to maximize your coverage.

If you ever have questions about your coverage, a claim you’ve seen online, or how your insurance affects your payment plan, just reach out, we’re happy to walk you through it.