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Apply for orthodontic treatment and reimbursement of the co-payment for orthodontic treatment from the statutory health insurance company


Statutory health insurance companies pay for orthodontic treatment for insured persons who have not reached the age of 18 at the start of treatment, if the treatment is medically necessary.

The orthodontist assesses whether the treatment is medically necessary for your child on the basis of so-called orthodontic indication groups (KIG) and their 5 degrees of severity. The statutory health insurance companies will cover the costs for your child from severity level 3. This means, for example, that a jaw or tooth misalignment already significantly impairs biting, mouth closure or joint function in your child or threatens to impair it in the future.

The orthodontist settles the orthodontic treatment directly with the Association of Statutory Health Insurance Dentists, minus your own contribution. Their own contribution amounts to 20 percent of the costs of the contract doctor. If you have more than one child undergoing orthodontic treatment, your co-payment for the second and each additional child is reduced to 10 percent of the costs of the contract doctor. The prerequisite is that they live in the same household.

If the treatment is successfully completed, the statutory health insurance company will reimburse you for your own contribution. To do this, you must submit an application to your health insurance company or your child's health insurance company and submit some documents, such as the final report from the orthodontist and the co-payment invoices with corresponding proof of payment.

Coverage for adults

The costs of orthodontic treatment, which is started from the age of 18, can only be covered by the statutory health insurance in very few exceptional cases. These include, for example, severe jaw anomalies, for which surgical corrections are also necessary. In these cases, your orthodontist will draw up a coordinated oral surgery and orthodontic treatment concept.
 

Process flow

To be reimbursed for your own contribution to orthodontic treatment, proceed as follows:

Standard care for children and adolescents:

  • The orthodontist will diagnose your child with a malocclusion of teeth from grade 3 and will draw up an orthodontic treatment plan. The orthodontic treatment plan includes
    • the planned therapeutic measures,
    • the expected duration of treatment, and
    • the expected cost.
  • The orthodontic practice submits the findings and the treatment plan to your statutory health insurance company or to the health insurance company with which your child is insured.
  • Treatment begins when the responsible health insurance company has approved the treatment plan.
  • During the treatment, the orthodontic practice settles 80 percent of the contract medical costs (90 percent for several children from the 2nd and 90 percent for each additional child) directly with the responsible health insurance company. The practice will send you an invoice per quarter for the remaining 20 percent (or 10 percent if you have multiple children).
  • You pay the invoice amount to the orthodontic practice.
  • Keep the invoices of the orthodontic practice as well as the corresponding payment receipts.
  • The orthodontic practice will issue a certificate of completion for you after the treatment has been successfully completed.
  • You apply for reimbursement of your own contribution to the responsible health insurance company and submit the necessary documents. You can submit the application by post or – in the case of many statutory health insurance companies – in person at the office.
  • Your statutory health insurance company will transfer the deductibles to you.

Exceptional indications in adults:

  • Your orthodontist will send the coordinated oral surgery and orthodontic treatment concept directly to your statutory health insurance company.

Requirements

  • You are a member of a statutory health insurance company.
  • In order to be reimbursed, your child must have successfully completed the treatment.

Which documents are required?

  • Orthodontic treatment plan
  • In order to be reimbursed for the co-payment, you will also need the certificate of completion from the orthodontist and the invoices for your co-payment
     

What are the fees?

  • You will not incur any costs for the application to the statutory health insurance company.
  • If your child is being treated with services that go beyond what is medically necessary, you will have to pay for it yourself. This applies, for example, to tooth-coloured brackets, smooth surface sealing or highly elastic wires made of special alloys.

What deadlines do I have to pay attention to?

As a rule, you do not have to observe any deadlines.

Processing duration

It usually takes about 2 to 5 business days to process.

In order to process and make a decision quickly, the health insurance company must have the necessary information and, if necessary, documents complete and meaningful.
The health insurance company decides on applications promptly, whereby the statutory processing deadline is observed in order to protect patients' rights.

Please note that the stated processing time is an average value for all health insurance companies. It may vary in individual cases. The exact processing time also depends on the complexity of the individual case and can be extended accordingly. The same applies if documents or records are sent to you or the health insurance company by post. An expert opinion may be required. This takes up to 6 weeks in addition.

Applications / forms

  • Forms available: yes
  • Written form required: no
  • Informal application possible: no
  • Personal appearance required: no
  • Online service available: no

Appeal

  • Contradiction
  • Complaint

Technically approved by

Federal Ministry of Health (BMG)
 

Professionally released on

19.01.2023

Author

The text was automatically translated based on the German content.

Source: Serviceportal Niedersachsen (Portalverbund des Bundes und der Länder)