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Schleswig-Holstein

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

Source: Zuständigkeitsfinder Schleswig-Holstein (Linie6PLus)

Service Description

Under certain conditions, statutory health insurance companies cover the costs of medically necessary orthodontic treatment for children and adolescents. You can have your own contribution reimbursed by your health insurance provider after treatment.

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.

Whether treatment is medically necessary for your child is assessed by the orthodontist on the basis of so-called orthodontic indication groups (KIG) and their 5 degrees of severity. Statutory health insurance companies pay the costs for your child from severity level 3, which means, for example, that a misaligned jaw or teeth is already significantly impairing your child's biting, mouth closure or joint function or threatens to do so in the future.

The orthodontist will settle the orthodontic treatment directly with the National Association of Statutory Health Insurance Dentists, minus your own contribution. Your own contribution is 20 percent of the costs paid by the panel doctor. If you have more than one child undergoing orthodontic treatment, your own contribution for the second and each additional child is reduced to 10 percent of the costs incurred by the panel dentist. The prerequisite is that they live in the same household.

Once the treatment has been successfully completed, the statutory health insurance fund will reimburse your own contribution. To do this, you must submit an application to your health insurance fund or your child's health insurance fund and submit a number of documents, for example the final report from the orthodontist and the co-payment invoices with corresponding proof of payment.

Cost coverage for adults

The costs of orthodontic treatment started from the age of 18 can only be covered by statutory health insurance in very few exceptional cases. These include, for example, severe jaw anomalies that require surgical correction. In these cases, your orthodontist will create a coordinated oral surgery and orthodontic treatment concept.


Process flow

Proceed as follows for the reimbursement of co-payments for orthodontic treatment:

Standard care for children and adolescents:

  • The orthodontist will diagnose your child with malocclusion from severity level 3 and draw up an orthodontic treatment plan. The orthodontic treatment plan includes
    • the planned therapeutic measures,
    • the expected duration of treatment and
    • the expected costs.
  • 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 once the relevant health insurance company has approved the treatment plan.
  • During treatment, the orthodontic practice settles 80 percent of the costs (90 percent for each additional child) directly with the relevant health insurance company. The practice will send you an invoice for the remaining 20 percent (or 10 percent if there are several children) per quarter.
  • You pay the invoice amount to the orthodontic practice.
  • Keep the invoices from the orthodontic practice and the corresponding payment receipts.
  • The orthodontic practice will issue a final certificate for you once treatment has been successfully completed.
  • You apply for reimbursement of your own contribution to the relevant health insurance fund 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 fund will transfer the co-payment to you.

Exceptional indications for 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 fund.
  • Your child must have successfully completed the treatment in order for the co-payment to be reimbursed.
Which documents are required?
  • Orthodontic treatment plan
  • The final certificate from the orthodontist and the invoices for your co-payment are also required for reimbursement of the co-payment
What are the fees?
  • You do not have to pay for the application to the statutory health insurance fund.
  • If your child is treated with services that go beyond what is medically necessary, you will have to pay for this yourself. This applies, for example, to tooth-colored brackets, smooth surface sealants 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

Processing normally takes around 2 to 5 working days.

The health insurance company must have the necessary information and any required documents in a complete and meaningful form in order to process and decide quickly.
The health insurance company decides on applications promptly, whereby the statutory processing period is adhered to in order to protect patients' rights.

Please note that the processing time stated 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 may be longer. 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 may take up to 6 weeks.

Legal basis
Appeal
  • Objection
  • Complaint
Applications / forms
  • Forms available: yes
  • Written form required: no
  • Informal application possible: no
  • Personal appearance necessary: no
  • Online service available: no
Author
Forwarding service: Deep link to the original portal

Spitzenverband Bund der Krankenkassen (GKV-Spitzenverband)

The text was automatically translated based on the German content.

Technically approved by

Federal Ministry of Health (BMG)

Professionally released on

19.01.2023

Teaser

Under certain conditions, statutory health insurance companies cover the costs of medically necessary orthodontic treatment for children and adolescents. You can have your own contribution reimbursed by your health insurance provider after treatment.

Process flow

Proceed as follows for the reimbursement of co-payments for orthodontic treatment:

Standard care for children and adolescents:

  • The orthodontist will diagnose your child with malocclusion from severity level 3 and draw up an orthodontic treatment plan. The orthodontic treatment plan includes
    • the planned therapeutic measures,
    • the expected duration of treatment and
    • the expected costs.
  • 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 once the relevant health insurance company has approved the treatment plan.
  • During treatment, the orthodontic practice settles 80 percent of the costs (90 percent for each additional child) directly with the relevant health insurance company. The practice will send you an invoice for the remaining 20 percent (or 10 percent if there are several children) per quarter.
  • You pay the invoice amount to the orthodontic practice.
  • Keep the invoices from the orthodontic practice and the corresponding payment receipts.
  • The orthodontic practice will issue a final certificate for you once treatment has been successfully completed.
  • You apply for reimbursement of your own contribution to the relevant health insurance fund 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 fund will transfer the co-payment to you.

Exceptional indications for 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 fund.
  • Your child must have successfully completed the treatment in order for the co-payment to be reimbursed.

Which documents are required?

  • Orthodontic treatment plan
  • The final certificate from the orthodontist and the invoices for your co-payment are also required for reimbursement of the co-payment

What are the fees?

  • You do not have to pay for the application to the statutory health insurance fund.
  • If your child is treated with services that go beyond what is medically necessary, you will have to pay for this yourself. This applies, for example, to tooth-colored brackets, smooth surface sealants 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

Processing normally takes around 2 to 5 working days.

The health insurance company must have the necessary information and any required documents in a complete and meaningful form in order to process and decide quickly.
The health insurance company decides on applications promptly, whereby the statutory processing period is adhered to in order to protect patients' rights.

Please note that the processing time stated 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 may be longer. 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 may take up to 6 weeks.

Legal basis

Appeal

  • Objection
  • Complaint

Applications / forms

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

Author

Forwarding service: Deep link to the original portal

Spitzenverband Bund der Krankenkassen (GKV-Spitzenverband)

The text was automatically translated based on the German content.

Technically approved by

Federal Ministry of Health (BMG)

Professionally released on

19.01.2023

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