Beam will make a payment for covered orthodontic services related to the initial orthodontic treatment which consists of diagnosis, evaluation, pre-care, and insertion of bands or appliances.
After the payment for the initial orthodontic treatment, benefits for covered orthodontic services will be paid in monthly installments as claims are submitted over the course of the remaining orthodontic treatment.
The benefit payment schedule for the initial orthodontic treatment and monthly installments will be determined as follows:
- We will determine the lesser of the MAC and the orthodontist’s fee and multiply that amount by the Insurance percentage shown in the schedule.
- The lesser of the amount from number 1 or the Overall Maximum Benefit for orthodontic services shown in the Schedule of Benefits will be the maximum benefit payable. An initial amount of 25% of the Overall Maximum Benefit payable will be paid for the initial orthodontic treatment. This amount will be payable as of the date appliances or bands are inserted.
- The remaining 75% of the Overall Maximum Benefit payable will be paid at the applicable coinsurance on a monthly basis as claims are submitted. The subsequent monthly payments will be made only if the dependent remains insured under the certificate and provides proof to us that orthodontic treatment continues. If orthodontic treatment continues after the Overall Maximum Benefit payable has been paid, no further benefits will be paid.
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The lifetime maximum is equal to the member’s lifetime maximum and is inclusive with the prior carrier, if applicable.