Initial Banding Claim Requirements
- Banding procedure date (Box 24)
- Banding procedure code (Box 29)
- Total charged amount (Box 31)
- Banding date (Box 41) [Date of service (Box 24) and banding date should match]
- Total months of treatment (box 42)
Work In Process Orthodontics Claim Requirements
- All EOB’s [if applicable] from previous carrier showing total paid amount. If there is no prior payments from a previously carrier, please indicate
- Monthly procedure date (Box 24)
- Monthly procedure code (Box 29)
- Monthly charged amount (Box 31)
- Total charged amount (Box 35 or separate narrative)
- Total months of treatment since banding date (Box 35 or separate narrative)
- Initial banding date (Box 41)
Monthly Orthodontics Claim Requirements
- Monthly claims must be submitted for ongoing orthodontic treatment payments. Please include the monthly procedure date (Box 24), monthly procedure code (Box 29), and monthly charged fee (Box 31).
To avoid delays in processing when submitting monthly claims, the appliance placed on date (Box 41) is required for benefit determination.