Common use of Class V - Orthodontic Services Clause in Contracts

Class V - Orthodontic Services. A. Benefits for orthodontic services will only be available until the end of the calendar year in which the Member turns age 19 if the Member: 1. Has fully erupted permanent teeth with at least 1/2 to 3/4 of the clinical crown being exposed (unless the tooth is impacted or congenitally missing); and 2. Has a severe, dysfunctional, handicapping malocclusion and is determined to be Medically Necessary. B. All comprehensive orthodontic services require a pre-treatment estimate (PTE) by CareFirst, as described in the Estimate of Eligible Benefits section. The following documentation must be submitted with the request for a PTE: 1. ADA 2006 or newer claim form with service code requested; 2. A complete series of intra-oral photographs; 3. Diagnostic study models (trimmed) with wax bites or OrthoCad electronic equivalent, and 4. Treatment plan including anticipated duration of active treatment. C. Covered benefits if a PTE is approved

Class V - Orthodontic Services. A. Benefits for orthodontic services will only be available until the end of the calendar year in which the Member turns age 19 if the Member: 1. Has fully erupted permanent teeth with at least 1/2 to 3/4 of the clinical crown being exposed (unless the tooth is impacted or congenitally missing); and 2. Has a severe, dysfunctional, handicapping malocclusion and is determined to be Medically Necessary. B. All comprehensive orthodontic services require a pre-treatment estimate (PTE) by CareFirst, as described in the Estimate of Eligible Benefits section. The following documentation must be submitted with the request for a PTE: 1. ADA 2006 or newer claim form with service code requested; 2. A complete series of intra-oral photographs; 3. Diagnostic study models (trimmed) with wax bites waxbites or OrthoCad electronic equivalent, and 4. Treatment plan including anticipated duration of active treatment. C. Covered benefits if a PTE is approved