Claiming Orthodontics

Orthodontics is a dentistry specialty that addresses the diagnosis, prevention, management, and correction of mal-positioned teeth and jaws, as well as misaligned bite patterns. Orthodontic treatment involves the design and use of corrective appliances (such as braces, plates, headgear, and functional appliances) to bring the teeth and jaws into proper alignment.

There is a 12-month waiting period before you’re able to claim for Orthodontics.

What if you transfer between health funds – do I have to re-serve waiting periods?
Orthodontic lifetime limits are transferrable between funds, which means that any limits you’re eligible for with your previous fund will transfer across with you to Phoenix Health. If you upgrade when you transfer to Phoenix Health, waiting periods will apply to any upgrade in benefits, limits or lifetime limits.

What if you upgrade your cover?
If you upgrade your cover to include Orthodontic benefits, or to increase your Orthodontic benefits, a 12 month waiting period will apply to any upgrade in benefits. During this time, where you were eligible for Orthodontic benefits, you’ll still be able to claim these up to your already eligible benefits, limits and lifetime limits.

For more information about waiting periods, click here.

Orthodontic benefits are available on select levels of Phoenix Health Extras and vary depending on your cover. You can check your level of cover and the benefits available by logging into your Online Member Services and viewing your Product Information Sheet – if you’re not sure, get in touch with the Phoenix Health team – we’d be happy to help!

Orthodontic benefits are claimable per person and have both annual limits (the maximum amount you can claim per calendar year) as well as lifetime limits (the maximum amount you can claim in a lifetime).

What is a Lifetime Limit?
A Lifetime Limit is the maximum benefit payable for the lifetime of the member – so literally the maximum amount you can claim in your lifetime.

What if you transfer between health funds?
Orthodontic lifetime limits are transferrable between funds, which means that any limits you’ve claimed with Phoenix Health will transfer with you if you ever move to another health fund and will count towards the limits you’ve used, and will transfer to Phoenix Health if you join us from another fund.

What if you upgrade your cover?
If you upgrade your cover to include Orthodontic benefits, or to increase your Orthodontic benefits, a 12 month waiting period will apply to any upgrade in benefits. During this time, where you were eligible for Orthodontic benefits, you’ll still be able to claim these up to your already eligible benefits, limits and lifetime limits.

You’ve been told you need Orthodontic treatment. You’ve been given a quote. What will Phoenix Health pay? Before you start any treatment, we recommend you get in touch with the Phoenix Health team so we can guide you through the claiming process and give you a quote for what benefits you’re eligible for.

To give you a benefit quote, you’ll need to get an itemised quote from your Orthodontist that includes the following details:

• The item numbers that will be used during your treatment.
  Most Orthodontic item numbers start with an ‘8’ and where eligible will be paid out of your Orthodontic benefits. If any general dental item numbers are also charged, these will be paid under General Dental.
• The cost per individual item
• Your Orthodontist’s provider number

What payment options are available to you?
We recommend that you discuss your payment options with your Orthodontist, as you may be able to pay your treatment off in instalments, or may even be offered a small discount for paying the entire fee upfront.

You are able to claim your Orthodontic benefits by:

• HICAPS, swiping your Phoenix Health member card at the time of service
• Phoenix Health App or Online Member Services
• Phoenix Health claim form, emailed to [email protected] or post to PO Box 156 Newcastle NSW 2300

As with any Extras claim, if you’re submitting your claim to us via the Phoenix Health App or Online Member Services, you’ll need to provide us with a copy of the itemized invoice for your treatment that includes the following information:

• Details of who received the treatment
• Details of the provider, including their provider number
• The date of service
• The item numbers for each service provided
• The fee for each item number charged

If you submit your claim to us manually, you’ll also need to complete a Phoenix Health Claim form to accompany your invoice.

If you pay for your treatment upfront in full…

• Year One – we will process your claim and pay the benefit up to the yearly limit available
• Year Two – to process the second year’s claim, we will require an updated itemised invoice showing that the patient is still actively receiving treatment that has been paid in full – you can get one of these at your regular check-up with your Orthodontist
• Year Three – same as Year Two, we’ll need an updated itemized invoice showing that the member is still in active treatment.

If you pay for your treatment in installments…
Submit your itemised invoice for the treatment you have paid for, and we will pay each claim up until your annual and lifetime limits.

If you’ve received an account for your treatment but haven’t paid it yet?
Benefits are only claimable once your account has been paid in full, or you have commenced paying by installments or payment plan.

What’s the difference between a Dentist and an Orthodontist?
Orthodontists and dentists both work together to help you improve your overall oral health – but they actually work in very different ways and it’s important that you know the key differences so you can make an informed decision when it comes to your treatment.

Dentists

• A general dentist is similar to your family GP medical doctor – they are highly skilled general practitioners who can diagnose and treat problems and common diseases that affect your teeth, mouth and gums.
• Dentists complete a General Dental Degree but unlike orthodontists, have not completed full-time university training to become a specialist in orthodontics.
• They are experts in general dental care and maintenance for all ages. They also perform cosmetic dental procedures such as tooth whitening, porcelain veneers and crowns.
• Most general dentists will refer patients to specialist orthodontists.

Orthodontists

• Orthodontists are registered dental specialists who have completed an additional three years of full-time university training in orthodontics, facial growth and development, biology and biomechanics (they hold a General Dental Degree + Specialist Orthodontic Degree). There are only 3-4 Orthodontists trained each year at 5 accredited Australian universities and only the best dentists are selected into these highly selective training programs.
• Orthodontists are facial growth and dental development experts. They know how to diagnose and treat crooked teeth, bad bites and poorly aligned jaws.
• Orthodontists are experts in all orthodontic care options (e.g. braces and clear aligner treatment) and emerging digital technologies for children, teens and adults.

*Source: Orthodontics Australia.

Can I claim Orthodontic benefits if the treatment is done by a Dentist?
Yes, you are able to claim Orthodontic treatment when provided by a General Dentist.

I paid for the orthodontic treatment in full while serving my waiting periods – can I claim once my waiting periods have been served?
No. Benefits are payable as at the date of service, so if you were within waiting periods at the time of treatment, no benefits will be payable on this treatment.

I paid for the orthodontic treatment in full while I was with my previous fund. Can I claim with Phoenix?
No. Benefits are payable as at the date of service, so if you weren’t a member of Phoenix Health at the time of treatment, no benefits will be payable on this treatment.

I’m paying for my orthodontic treatment in instalments, but I’m currently in waiting periods – can I claim a benefit when my waiting periods have been served?
Yes, but only for instalments that are paid after your waiting periods have been completed.

I started my treatment and paying by instalments with another fund, now I’m with Phoenix Health can I claim Orthodontic benefits?
Yes, but only for instalments that are paid after you’ve joined Phoenix Health. Any limits you’ve claimed already with your previous fund will transfer with you, however you’ll be able to claim these up to your eligible benefits, limits and lifetime limits.