responsibility finder
Schleswig-Holstein

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

Source: Zuständigkeitsfinder Schleswig-Holstein (Linie6PLus)

Service Description

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.

The orthodontist will assess whether the treatment is medically necessary for your child based on so-called orthodontic indication groups (KIG) and their 5 degrees of severity. The statutory health insurance companies will pay for your child's orthodontic treatment from severity level 3, which means, for example, that a jaw or tooth misalignment already significantly impairs your child's biting, mouth closure or joint function, or threatens to do so in the future.

The orthodontist will bill the Kassenzahnärztliche Vereinigung directly for the orthodontic treatment, minus your own contribution. Your co-payment amounts to 20 percent of the SHI-accredited costs. If you have more than one child undergoing orthodontic treatment, your co-payment for the second and each additional child is reduced to 10 percent of the SHI-accredited costs. The prerequisite is that they live in the same household.

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

Cost absorption for adults

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


Process flow

For reimbursement of copayments for orthodontic treatment, proceed as follows:

Standard care for children and adolescents:

  • The orthodontist identifies a malocclusion in your child's teeth of severity 3 or higher and prepares an orthodontic treatment plan. The orthodontic treatment plan contains
    • the planned therapeutic measures,
    • the expected duration of treatment and
    • the estimated costs.
  • The orthodontic practice submits the findings and the treatment plan to your statutory health insurance fund or to the health insurance fund with which your child is insured.
  • Treatment begins when the relevant health insurance company has approved the treatment plan.
  • During the treatment, the orthodontic practice settles 80 percent of the statutory health insurance costs (in case of several children from the 2nd and for each additional child 90 percent) directly with the responsible health insurance company. The practice sends you an invoice for the remaining 20 percent (or 10 percent in the case of several children) per quarter.
  • You pay the invoice amount to the orthodontic practice.
  • Keep the orthodontic practice's invoices and the accompanying payment receipts.
  • The orthodontic practice will issue a certificate of completion for you upon successful completion of treatment.
  • You apply for reimbursement of the co-payment made to the relevant health insurance fund and submit the necessary documents. You can submit the application by mail and - for 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 fund.
Requirements
  • You are a member of a statutory health insurance fund.
  • For reimbursement of the co-payment, your child must have successfully completed the treatment.
Which documents are required?
  • Orthodontic treatment plan
  • For the reimbursement of the co-payment, the final certificate from the orthodontist and the invoices for your co-payment are also required
What are the fees?
  • You will not incur any costs for the application to the statutory health insurance.
  • 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 usually takes about 2 to 5 working days.

For rapid processing and decision-making, the health insurance fund must be provided with the necessary information as well as any required documents in a complete and meaningful manner.
The health insurance company decides on applications promptly, while adhering to the statutory processing time limit in order to protect patients' rights.

Please note that the processing time indicated is an average value for all health insurance funds. It may vary in individual cases. The exact processing time also depends on the complexity of the individual case and may be longer accordingly. The same applies if documents or records are sent to you or the health insurer by mail. An expert opinion may be required. This takes up to an additional 6 weeks.

Legal basis
Appeal
  • Objection
  • Complaint
Applications / forms
  • Forms available: yes
  • Written form required: no
  • Informal application possible: no
  • Personal appearance required: no
  • Online service available: no
Technically approved by

Federal Ministry of Health (BMG)

Process flow

For reimbursement of copayments for orthodontic treatment, proceed as follows:

Standard care for children and adolescents:

  • The orthodontist identifies a malocclusion in your child's teeth of severity 3 or higher and prepares an orthodontic treatment plan. The orthodontic treatment plan contains
    • the planned therapeutic measures,
    • the expected duration of treatment and
    • the estimated costs.
  • The orthodontic practice submits the findings and the treatment plan to your statutory health insurance fund or to the health insurance fund with which your child is insured.
  • Treatment begins when the relevant health insurance company has approved the treatment plan.
  • During the treatment, the orthodontic practice settles 80 percent of the statutory health insurance costs (in case of several children from the 2nd and for each additional child 90 percent) directly with the responsible health insurance company. The practice sends you an invoice for the remaining 20 percent (or 10 percent in the case of several children) per quarter.
  • You pay the invoice amount to the orthodontic practice.
  • Keep the orthodontic practice's invoices and the accompanying payment receipts.
  • The orthodontic practice will issue a certificate of completion for you upon successful completion of treatment.
  • You apply for reimbursement of the co-payment made to the relevant health insurance fund and submit the necessary documents. You can submit the application by mail and - for 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 fund.

Requirements

  • You are a member of a statutory health insurance fund.
  • For reimbursement of the co-payment, your child must have successfully completed the treatment.

Which documents are required?

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

What are the fees?

  • You will not incur any costs for the application to the statutory health insurance.
  • 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 usually takes about 2 to 5 working days.

For rapid processing and decision-making, the health insurance fund must be provided with the necessary information as well as any required documents in a complete and meaningful manner.
The health insurance company decides on applications promptly, while adhering to the statutory processing time limit in order to protect patients' rights.

Please note that the processing time indicated is an average value for all health insurance funds. It may vary in individual cases. The exact processing time also depends on the complexity of the individual case and may be longer accordingly. The same applies if documents or records are sent to you or the health insurer by mail. An expert opinion may be required. This takes up to an additional 6 weeks.

Legal basis

Appeal

  • Objection
  • Complaint

Applications / forms

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

Technically approved by

Federal Ministry of Health (BMG)

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