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Dental HMO Continuing Orthodontic Treatment Request Form Rebranded Version 1-11-19 (2) docx

Dental HMO Continuing Orthodontic Treatment Request Form Rebranded Version 1-11-19 (2) docx 2025

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4.8 out of 5

56 votes

The document is a Continuing Orthodontic Treatment Request Form for members of MetLife Health Plans and SafeGuard Health Plans. It outlines the eligibility criteria for continuing orthodontic treatment under specific circumstances, such as prior coverage or active treatment before the current plan's effective date. The form requires detailed subscriber and orthodontist information, along with necessary documentation to process the request within thirty days. It also specifies that SafeGuard will cover up to $1,500 of the remaining balance owed for orthodontic treatment.

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Versions	Form popularity	Fillable & printable
2017	4.8 Satisfied (56 Votes)
2014	4 Satisfied (56 Votes)

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What is the ADA code for orthodontic visit?

CODE DEFINITION D8660 Pre-orthodontic treatment visit D8670 Periodic orthodontic treatment visit (as part of contract) D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)).

What is the ADA code for orthodontic consultation?

Dental Code D8660: Pre-Orthodontic Examination for Growth.

What is the dental code for continuation of care?

Services billed with CDT D0150 (comprehensive oral evaluation - new or established patient), D0145 (oral evaluation for a patient under three years of age and counseling with primary caregiver), and D0120 (periodic oral evaluation - established patient) for dental exam/evaluation will count towards a continuity of care