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Submit costs for implants or orthodontic treatment for adults to the statutory health insurance fund in cases of special exceptions


If you have statutory health insurance, many of your dentist's services are free of charge for you and are billed via your electronic health card (eGK): This applies, for example, to the removal of caries and the filling of holes.

Additional cost regulation for dental fillings

You are entitled to fillings made of the cheapest material. In addition to this standard supply, you can also choose other materials. In these cases, you only have to pay the additional costs privately.
If you opt for a more expensive material for which you will cover part of the costs yourself, conclude a so-called additional cost agreement with your dentist. Your dentist will bill the health insurance company for the services to which you are entitled under standard care. You will receive an invoice from your dentist for the additional services.

Subsidy for dentures

For the provision of dental prostheses (e.g. crowns or bridges), you will receive precisely defined amounts from your health insurance company as fixed subsidies. The amount of the fixed subsidy is 60 percent of the average costs for standard care and can rise to 70 or 75 percent if you have regularly attended preventive check-ups in the last 5 or 10 years before the start of treatment and the examinations are documented in your bonus booklet.

Costs that exceed the statutory reimbursement amount must be borne by you yourself. Your health insurance company can cover a further amount of the costs if you only have a low income or receive certain social benefits (e.g. BAföG, social assistance or unemployment benefit II).

If you have private supplementary dental insurance, you may be able to submit additional cost invoices, co-payment invoices and private bills there, depending on the contract. In any case, it is advisable that you inform your private supplementary insurance before the start of treatment and clarify what must be taken into account for any possible reimbursement or which documents are required for this.

Orthodontics

You or your child are entitled to orthodontic care if there is a medically justified indication and you or your child have not yet reached the age of 18 at the start of treatment. Adults usually have to pay for orthodontic treatment themselves. Only in medically justified exceptional cases, for example in the case of severe jaw anomalies in which surgical corrections are also necessary, can insured persons over the age of 18 also be entitled to benefits.

Dental Implants

You will also have to pay for the cost of a dental implant and implant surgery yourself. Only in severe and special exceptions does the health insurance company contribute to implants, for example as part of an overall medical treatment after tumor surgery.
 

Process flow

In case of exceptional indications:

You can submit the treatment and cost planning together with the treatment and cost plan for the prosthetic treatment by post or – in the case of many statutory health insurance companies – in person at the office.  

  • In the case of implantological or orthodontic services in exceptional indications, your dentist will prepare a cost estimate.
  • Your dentist will send the cost estimate directly to your statutory health insurance company.
  • Your statutory health insurance company will review the application and inform you of whether it has been approved or rejected.

Additional costs, private billing, co-payment:

  • You will receive an invoice from your dentist and pay the invoice amount.
  • If you have private supplementary insurance, you can ask them whether the costs incurred by you will be reimbursed and what documents are required for this.
  • If your private supplementary insurance requires a rejection notice from the statutory health insurance company, submit the invoice to your statutory health insurance company.
  • Your statutory health insurance company will review the application and send you a rejection notice.
  • You must submit the rejection to your private supplementary dental insurance.
  • Depending on the contract, your private dental insurance will reimburse you for the agreed share of the total bill.

Requirements

  • You are a member of a statutory health insurance company.
  • The treatment and cost plan has been approved by your statutory health insurance company before the start of treatment.
  • The treatment and cost planning or the oral surgery and orthodontic treatment concept have been approved by your statutory health insurance company.
     

Which documents are required?

Depending on which dental or orthodontic service you receive, your health insurance company may require the following documents before starting treatment in certain cases:

  • Treatment and cost plan
  • If applicable, invoice from the dentist including laboratory invoices
  • Bonus booklet (copy) if applicable
  • in particularly severe cases (exceptional indications):
    • Estimate
  • for orthodontic treatment for adults:
    • Oral surgery and orthodontic treatment concept

Please contact your health insurance company to clarify which documents are required.
 

What are the fees?

  • You will not have to pay any costs for the application to your statutory health insurance company.
  • Any additional costs will have to be borne by you.

What deadlines do I have to pay attention to?

You don't have to observe any deadlines.

Processing duration

It usually takes 2 to 7 business days to process.

In order to process and make a decision quickly, your 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 your health insurance company by post.
If necessary, an expert opinion must be obtained. This takes up to 6 weeks in addition.
 

Appeal

  • Contradiction
  • Appeal to the Social Court

Technically approved by

Federal Ministry of Health (BMG)

Professionally released on

16.06.2023

Author

The text was automatically translated based on the German content.

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