Dental care is one of the most demanding healthcare specialties, majorly due to an increase in patient volume. According to the National Institute of Dental and Craniofacial Research (NIH), 90% of adults aged 20 to 64 years suffer from tooth decay in the USA. Other gum diseases are also found in 50% of adults between the ages of 45 and 64 years. NIH also states that untreated tooth decay has led to a productivity loss of $45.9 billion. With such a significant increase in the need for dental care, dental billing has become a determining factor for dental clinics for financial stability.

 

While dentistry focuses on overall dental health, orthodontic being a specialized branch of dentistry, specializes only in the alignment of teeth and gums. Since orthodontic care often lasts for more than a year, the billing process is more complex than standard dental billing. It involves treatment contracts, installment payments, and ongoing insurance claims. Like every other healthcare specialty, the orthodontic reimbursement process also includes documentation, prior authorization, coding, and other necessary billing methods.

 

A comprehensive dental billing workflow for orthodontic practices

When dentists provide orthodontic treatment to patients, they receive reimbursement from the patient’s insurance company. This reimbursement or payment goes through multiple stages before they reach the provider. Every dental clinic has their own in-house billing team who take care of the reimbursement process. In many cases, providers hire outsourced billing companies to ensure proper reimbursement. The different stages of orthodontic billing include:

 

  1. Documentation – This is the first step in the orthodontic billing process and involves collecting the patient’s details and insurance information. Many orthodontic treatments extend beyond months to even years. The documentation process also includes registering correct information on diagnosis, estimated treatment duration, and expected outcomes. Patient registration and documentation serve as the foundation for the entire dental billing process.  
     
  2. Insurance eligibility - Insurance eligibility in orthodontic billing is the process of verifying a patient’s orthodontic insurance benefits before starting treatment such as braces or clear aligners. It ensures the orthodontic practice understands exactly what the insurance plan will cover and what the patient must pay out of their pocket. For orthodontic billing, billers must confirm whether orthodontic benefits are included in the plan, percentage of coverage, deductible requirements, age limitations, and other requirements. Proper verification of insurance eligibility helps practices avoid underestimating treatment costs, reduce denials, and improve long-term revenue generation. 
     
  3. Coding – Dental billing is a tricky process where providers can face penalties if patient data is not protected. To safeguard sensitive patient health information (PHI), the patient's demographics are encrypted into alphanumeric entities known as codes. These standardized codes maintain uniformity and help in the reimbursement of dental services. The billers select the correct CDT code for orthodontic treatments and submit claims to the insurance company for reimbursement. Some of the commonly used CDT codes are: 
    1. D8010-D8060 for limited and interceptive treatment  
    2. D8070-D8090 for comprehensive treatment
    3. D8660 for monitoring growth, also known as pre-orthodontic exam
    4. D8670 for periodic treatment visit 
       
  4. Prior authorization – After the documentation process is completed, prior authorization is required by the insurance companies. It refers to the process of getting approval from the insurance company before proceeding with any orthodontic treatment. The payers (insurance companies) review the treatment plan to decide whether the treatment is medically necessary. Prior auth is an important part of orthodontic treatment since it involves long-term and expensive care. Some of the common services that require authorization are comprehensive treatment of braces, clear aligner therapy, and other adult orthodontic cases. The documents required for PA include panoramic X-ray, intraoral and extraoral photographs, and digital scans.  
     
  5. Claim submission - Once orthodontic treatment is completed, claims are sent to the patient’s insurance company for reimbursement, including patient and provider details, service codes, and fees. The payer evaluates the submitted claim along with the patient’s insurance coverage policy. If all requirements and conditions are fulfilled, the insurance company approves the claim and proceeds with payment to the dental clinic. The payment covers the treatment expenses enlisted in the insurance coverage plan. Claim denials are major obstacles in the reimbursement process, so accurate claim submission is essential to prevent them. In most cases, the in-house dental billing teams submit claims electronically.  
     
  6. Claims follow-up – It is common for orthodontic claims not to be approved on the first submission, and some may be denied or require additional information. Through continuous claim monitoring, clinic staff can determine the causes of denials and provide the necessary information for proper adjudication. Most of the orthodontic claims are denied due to incomplete documentation, missing CDT codes, and insurance policy limitations. After identifying the issue, the billers may submit missing documents, rectify and resubmit claims, and file appeals for denied claims. 
     
  7. Payment posting - Following claim adjudication and payer processing, payment posting is initiated, which involves reconciling received payments with the reimbursement details provided in the Explanation of Benefits (EOB). This process is highly detail-oriented and ensures that all payments are appropriately allocated to their respective services.  Payment posting includes updating the patient’s account balance to reflect any outstanding amount or applicable credit, if present. The internal dental billing teams review claim information, procedure codes, allowed vs. billed amounts, and patient responsibility amounts. The payment amounts are entered into the practice management systems. The insurance payments are applied to specific orthodontic services, and patient payments are recorded accurately. After posting, payments are matched against charges, and the remaining balances are calculated. 
     
  8. Accounts receivable closure - Accounts receivable in orthodontic billing refers to the total amount of money a dental practice expects to collect for treatments provided. When a dentist has rendered services and the insurance company has not yet issued payment, the outstanding amount is classified as accounts receivable. Medical billers consistently work to minimize the accounts receivable (AR) bucket to ensure timely and accurate reimbursement for dental practitioners. AR is generated in case of orthodontic treatment, claim submission, or a patient has an unpaid balance. For example, if a patient begins braces treatment and insurance company has not yet paid their portion, that amount becomes part of AR.

 

 

Major orthodontic RCM challenges impacting dental clinics 
 

  • Installment plan management – The banding fee coupled with installment plan structure is one of the trickiest components of orthodontic billing. This is because it involves clinical targets, insurance timing, and long-term financial contracts into a single patient case. Most orthodontic treatments are billed as a single comprehensive fee at banding. Later, they are split between insurance installments and patient payment plans over 18-36 months. In many cases, patients assume that banding is the same as the payment of full treatment. The payers may or may not reimburse the banding fee separately. Without a proper tracking infrastructure, installment arrears transform monthly into normalized revenue leakage. Orthodontic insurance benefits are often paid as a lifetime maximum or partially at the start of active treatment. The patient's responsibility changes after insurance adjudication, and providers struggle to rebalance ledgers after insurance posting.  
     
  • Clear verification of benefit – The verification of clear aligner has become one of the most error-prone areas in orthodontic revenue cycle management. Some insurance plans treat clear aligners as orthodontic benefits while others treat them as cosmetic services or elective procedures. The benefit verification teams often receive conflicting responses from payers, which leads to incorrect patient estimates. Even when are covered under the insurance plan, insurers may apply different internal rules for aligners and braces. Unlike many dental procedures, orthodontic prior authorization for teeth aligners is often optional or non-binding. This creates a big difference between the estimate and final reimbursement.  
     
  • Lack of information - Insufficient or incorrect data is a leading cause of delays and denials in dental claims processing. Accurate patient demographics and insurance information help ensure clean claim submissions and smoother reimbursement. Denials related to incorrect beneficiary identification commonly arise from inaccuracies in the patient’s name or enrollee identification number submitted on the claim. Orthodontic claims are frequently denied due to insufficient supporting documentation, including clinical notes, radiographs, operative reports, dental histories, and sedation records. One of the common issues in missing information such as coverage limitations, coverage policy of clear aligners, and coordination of benefits for dual insurance cases. The billing teams often find it difficult to document banding or start of aligners, active treatment phase, extensions, and retention phase. Incomplete information is a major reason behind claim denials since it disrupts the alignment between clinical events, insurance rules, and financial workflows. 
     
  • Delayed claim submission - Since orthodontic treatment spans several months or years and often involves multiple billing milestones, timely claim submission is essential to ensure efficient revenue cycle management. Adhering to timely filing requirements is essential, as claims submitted after the payer's deadline may be denied regardless of coding accuracy or supporting documentation. Each insurance payer establishes its own Timely Filing Limit (TFL) for claim submission. Claims filed after this deadline are generally denied, making timely submission essential after dental services are provided. Timely filing limits vary by payer, and resubmitted claims may also be denied if they are not received within the applicable filing deadline. Orthodontic claims frequently require supporting documentation such as:
     
    • Clinical notes
    • Diagnostic records
    • Treatment plans
    • Prior authorization approvals. 
       
  • Inadequate staff training and audit – The absence of a formal audit trail prevents clinics from tracking who assigned or entered individual procedure codes. Lack of proper staff training can lead to difficulties in staying aligned with updated coding and billing guidelines. The American Dental Association offers seminars and online courses to help dentists and billing staff stay updated with coding updates and best practices. The insurance companies have frequent changes in rules regarding orthodontic coverage limits and documentation requirements. Without proper training, the in-house staff struggle to stay aligned with the billing changes. This leads to incorrect claim submission and revenue leakage.  
     

Common CDT challenges that slow down reimbursement

Orthodontic claims depend on the correct application of procedures and diagnosis codes that reflect the true nature of treatment. It is crucial for dental billing teams to stay updated with changing coding guidelines to clean claim submission. Using inaccurate, outdated, or discontinued codes can lead to denials and other reimbursement challenges. Dental procedures are typically reported using CDT codes, while CPT codes may apply to select procedures depending on payer requirements. Accurate code selection and adherence to the attachment requirements for each CDT procedure are critical for successful claim submission. Some of the major CDT coding challenges are:

 

  1. Missing D8660 submissions – Among all the other billing challenges, lack of D8660 is the most expensive hindrance. Submission of the monthly D8660 claim, which initiates each installment payment, is the responsibility of the provider. When the internal dental billing team submits monthly claims reactively instead of following a structured process, some submissions may be missed or delayed. This creates gaps in the installment schedule and results in accounts receivable that require manual follow-up. The objective is to implement a structured process in which monthly claim generation is automated or assigned as a recurring task with designated responsibility and a fixed completion date for all active cases. 
     
  2. Confusion between D8080 and D8090 – It often gets difficult for billers to distinguish between these two CDT codes. D8080 is used for comprehensive orthodontic treatment of the adolescent dentition. However, the D8090 is used for the comprehensive treatment of adult dentition. The confusion occurs because of the following reasons:
     
    1. Patient age is used instead of dental development stage 
    2. Lack of proper clinical documentation of dentition status  
    3. Staff misunderstanding the classification of teen vs adult
    4. Software defaults or template errors  
    5. Incomplete orthodontic records review before billing

      The incorrect use of D8080 and D8090 results in claim denials, downcoding, audit risk, and reduced quality of patient care. 
       
  3. Misuse of Interceptive vs Comprehensive Codes - One of the most common orthodontic billing errors is the incorrect use of interceptive and comprehensive CDT codes, which often leads to claim denials, underpayment, or compliance issues. The confusion usually comes from misunderstanding the stage of treatment rather than the actual clinical intent. For example, using D8060 or D8070 while the patient is already in full braces leads to underpayment, claim disputes, and incorrect tracking of benefits.



It is no surprise that internal billing teams struggle to manage the different billing and coding challenges of orthodontics. Even with best practices, it becomes difficult to reduce denial rates due to multiple billing complications. This is why most dental clinics prefer outsourcing over in-house billing staff due to the advantages they offer. However, in-house billers still offer some benefits that are absent from outsourced companies. It now depends on providers to select an option based on their requirements.

 

The decision to select in-house or outsourced dental billing

 

It is evident that managing all the complexities of dental billing is a mammoth task for internal billers. This not only increases claim denials but leaves the practice vulnerable to penalties and patient dissatisfaction. With outsourced dental billing companies, orthodontic reimbursement becomes easy due to the wide range of benefits. The third-party firms have trained staff, certified coders, and several years of experience that make them the right choice for orthodontic billing. However, with outsourcing, some providers have felt that there is a lack of communication between them and third-party companies. Furthermore, in-house dental billing offers better control over the revenue cycle, faster communication between clinical and billing teams, and higher data security. As long as the services are reimbursed on time and patients receive high-quality treatment, outsourcing will continue to be the preferred option for dental practitioners.