Submit costs for implants or orthodontic treatments for adults to the statutory health insurance company in cases of special exceptions
If you have statutory health insurance, many services provided by your dentist 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 bear part of the costs yourself, you 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 dental prostheses
For the supply 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 been regularly at the check-up 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 legally regulated reimbursement amount must be borne by you. Your health insurance company can cover an additional amount of the costs if you 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 invoices there, depending on the contract. In any case, it is advisable that you inform your private supplementary insurance company before the start of treatment and clarify what must be taken into account for any reimbursement that may be considered or what 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, where 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 bear the costs for a dental implant and the implant operation yourself. Only in severe and special exceptions does the health insurance company participate in implants, for example as part of an overall medical treatment after tumor surgery.
Process flow
For exceptional indications:
You can hand in 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 for 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 whether it has been approved or rejected.
Additional costs, private billing, own contribution:
- 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 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 submit the rejection to your private supplementary dental insurance.
- Depending on the contract, your private supplementary 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 has been approved by your statutory health insurance company.
Which documents are required?
Depending on which dental or orthodontic service you use, in certain cases your health insurance company will require the following documents before starting treatment:
- Treatment and cost plan
- If applicable, invoice from the dentist including laboratory invoices
- If applicable, bonus booklet (in copy)
- in particularly severe cases (exceptional indications):
- Estimate
- for orthodontic adult treatment:
- 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 incur any costs for the application to your statutory health insurance company.
- You will have to bear any additional costs yourself.
What deadlines do I have to pay attention to?
You don't have to pay attention to any deadlines.
Processing duration
Processing usually takes 2 to 7 business days.
For a quick processing and decision, your health insurance company must have the necessary information and, if necessary, the necessary documents complete and meaningful.
The health insurance company decides on applications in a timely manner, whereby the statutory processing deadline is observed in order to protect patients' rights.
Please note that the stated processing time is an average value of 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 by post to you or your health insurance company.
If necessary, an expert opinion must be obtained. This requires an additional 6 weeks.
Appeal
- Contradiction
- Action before 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.
