Orthodontic claim message types
There are 9 message types for orthodontic claims, one is for prior approvals and 8 are for different types of payment. Ensure you are selecting the correct message type for the type of claim you are submitting.
Prior Approvals (Message type A)
Prior approval is required if the total cost for a course of treatment exceeds the prior approval limit or any individual items of treatment require approval, as indicated with an asterisk in the Statement of Dental Remuneration (SDR) or detailed in the discretionary fee guide.
Your prior approval request must include any retainer appliances you plan to use during the retention phase of the treatment plan. Practitioner Services will return any prior approval submissions that do not include the retention proposals.
When calculating the cost of treatment to determine whether prior approval is required, diagnostic items are not included in the total, for example examination, X-rays, photographs and study models.
Cases with an IOTN DHC of 1 will not be considered for orthodontic treatment under GDS due to the lack of health benefit. These cases will be automatically rejected.
Where a course of treatment has previously been approved and the treatment plan is being changed, you are required to amend the treatment plan on your PMS and apply for re-approval.
Interim Payments (Message type B) Only one interim payment can be claimed per course of treatment and can only be claimed when appliances have been fitted. When applying for interim payment, you will indicate how many of each of the following items have been fitted in the patient’s mouth: 32(a)1, 32(a)2, 32(a)3 and 32(a)4, then provide the item code for the interim payment fee you are claiming, these codes are detailed in the discretionary fee guide.
Examinations (Message type C) These are payment claims for examinations and where appropriate any diagnostic codes, for example, models, radiographs, and photographs. Claims will be rejected if the acceptance date and completion date are not the same and if all teeth charted are deciduous.
Final Payment (Message type D) A final payment should only be made where you have completed all treatment and/or you have requested and received a fee for discontinued treatment. Claims that received prior approval must include the approval date and reference before submitting. The 30-digit approval reference will look like: QVLZBWYITATRGZKCB49HKF7T6V5RCV.
If the treatment plan previously received approval, the items of treatment and total amount claimed on a Final Payment claim must match, or be less than, the treatment on the original approval. If an interim payment has previously been claimed for this course of treatment, a corresponding interim payment recovery code must be included on this claim, these codes are detailed in the discretionary fee guide.
Discretionary Items (Message type E) When claiming for only a discretionary item (not continuation or transfer cases), you must include observations to explain the treatment carried out.
Retention (Message type F) If the difference between the date of acceptance and date of completion is less than the number of months being claimed for retention, the claim will be rejected. Codes 3231 and 3232 are allowed on this claim.
Retainers (Message type G) Retainers should be claimed on the final payment, but there may be occasions where they can be claimed separately on a Retainers claims. No referral codes can be submitted. Codes for retainers are 3233, 3234, 3235, 3236, 3237 and 3238.
Regulation 9 (Message type H) Regulation 9 is the process for obtaining funding to replace lost/broken orthodontic appliances, due to an act or omission by the patient. You must obtain the regulation 9 decision from your NHS Board before submitting the claim for processing. Submit a regulation 9 claim completing the following fields:
- Health Board decision on patient contribution – This is the portion of the costs the patient is to contribute. Select from ‘All, ‘None’ or ‘Part’
- Amount patient is due – Indicate any amount the patient is due
- Did the patient pay a deposit? – Indicate whether the patient paid a deposit
- Deposit Value – Indicate the value of the deposit if deposit was taken
- Was the deposit refunded? – Indicate whether the deposit was refunded
- Reason for replacement – Select from ‘Lost or broken’ or ‘Does not fit’
- Remarks – Add any information pertinent to the claim
- Appliance original fitting date – You must enter the date the appliance was originally fitted We will return the submitted claim as an information request so you can upload a copy of the NHS Board decision.
Discontinued Fee Request (Message type I)
If you start a course of active treatment but cannot complete it, you must submit a discontinued fee request for the appliances you fitted. This may be due to the patient failing to return, having poor oral hygiene meaning treatment cannot continue, or where another practitioner within your practice will be taking over the patient’s treatment.
If you have only carried out the exam including x-rays, models, photos and will not be starting the active treatment, do not submit a discontinued fee request, you should only submit an Examination claim. The following details need to be specified for each discontinued appliance:
- Item Code – 4-digit item code from the SDR
- Period of Retention – number of months of retention (if appropriate)
- Number of Visits – indicate the number of visits
- Appliance made but not fitted – indicate if appliance has been made and not fitted
- Overjet on last visit for functional appliance (if appropriate): type – select from ‘Edge-to-edge’, ‘+’ or ‘-’ size – number from 0 to 12, can include 1 decimal point
- Teeth banded/bonded – indicate the teeth that have been banded/bonded (if appropriate)
- Final study models are available – indicate whether final study models are available
- Consultant’s report available – indicate whether consultant’s report is available
- Radiographs available – indicate whether radiographs are available You must also indicate in observations whether the patient has been de-bonded or not. We will return the codes and fees awarded for each discontinued appliance to use in your Final Payment.
A continuation case is where a course of treatment is started under one list number and continued under another list number within the same practice location.
- The same date of acceptance must be used on all parts, to reflect that it is one course of treatment.
- The patient charge is calculated across all continuation parts and therefore cannot exceed the maximum charge.
- Separate parts must be submitted in the correct sequence, and it is advisable for each dentist to submit their claim as soon as they complete their part of the treatment.
Dentist 1 (Practice A): If the course of treatment exceeds the prior approval limit or contains individual items that require approval according to the SDR, you must submit a prior approval request. You must receive approval before you can begin treatment.
Where you have fitted appliances but are unable to complete the patient’s treatment, submit a discontinued fee request. We will return the codes and fees awarded for each discontinued appliance to be submitted in your final payment. You should then submit a final payment for all completed items, along with the codes and fees we supplied for any discontinued appliances, which replace the original codes and fees for the discontinued appliances.
If all the items of treatment you started have been completed and there are no appliances in situ when you pass the patient’s treatment to your colleague, do not submit a Discontinued Fee Request, you should submit a final payment for those completed treatments.
If you have only carried out the examination (and where appropriate any diagnostic codes) and will not be starting the active treatment, do not submit a discontinued fee request. You should only submit an examination claim and do not include continuation case details.
Dentist 2 (Practice A – same practice location):
If originally approved, only submit for re-approval if the original treatment plan has changed. Do not include any complete treatment or partially paid treatments claimed by Dentist 1. Only include any items of treatment not started by dentist 1 and any additional treatment required. You can use discretionary code 3913 01 to request balance fees for the appliances discontinued by dentist 1. Add observations to explain this is continuation case part 2, detail any changes you have made provide details for the part 1, dentist list number, claim ID and previous prior approval reference. If the case is re-approved, we will return a value for the 3913 01 code along with the re-approval reference code. You must receive reapproval before you can begin treatment.
If the case did not originally require prior approval, submit for approval only if any individual items added require approval according to the SDR, or if the total cost of the whole treatment now exceeds the prior approval limit. You must have received approval before you can begin treatment.
If you have completed all treatment and there is no treatment outstanding, submit a final payment. This claim should only include any treatment started and completed by you and code 3913 01 for the balance of fees for the appliances discontinued by dentist 1 if they fitted the appliances. If you applied for re-approval, you will already have been provided with a fee for code 3913 01 (if applicable), which should be added to the claim against the item code.
If you are claiming a balance of fees for code 3913 01 and have not already been awarded a fee, submit the final payment claim with observations and we will return the claim to you informing you of the fee awarded. You should then re-submit your final payment, adding the value provided to the 3913 01 code. If you have not completed all treatment, you must follow one of the processes below, depending on when you took over treatment:
You took over treatment before active phase was started, for example, you fitted the appliances currently in situ: submit a discontinued fee request for the appliances you are discontinuing
When you receive the codes and fees for the discontinued appliances, submit a final payment for any treatment you started and completed, along with the codes/fees for the discontinued appliances
Include the continuation case details - previous claim ID and part number (this will be 2).
Took over treatment after active phase was started for example you did not fit the appliances currently in situ): Do not submit a discontinued fee request, as you did not fit the appliances. Submit a final payment and include:
any items of treatment started and completed by you
zero-value discretionary code 3913 01
observations detailing the number of visits for each appliance and if de-bonded
when you receive the fee we have awarded for the appliance visits, re-submit your final payment
Include the continuation case details - previous claim ID and part number (this will be 2) We will validate your payment claim against the approval and discontinued fee request before we authorise your claim for payment.
The same processes detailed for dentist 2 can be applied to any subsequent continuation of treatment with dentist 3 or higher from the same practice location.
A transfer case is where a course of treatment is started under one list number and completed under another list number at a different practice location.
Dentist 1 (Practice A):
Submit a discontinued fee request if you fitted appliances but are unable to complete the treatment. Then submit a Final Payment for all completed items, along with the codes and fees we supplied for any discontinued appliances, which replace the original codes and fees for the discontinued appliances. If all the items of treatment you started have been completed and there are no appliances in situ, do not submit a discontinued fee request. Submit a Final Payment for those completed treatments. If you have only carried out the examination and any diagnostic codes (for example, models, radiographs, and photographs) and will not be starting the active treatment, do not submit a discontinued fee request. You should only submit an examination claim.
Dentist 2 (Practice B – different practice location):
You must submit a prior approval claim adding code 3861 which is a zero-value discretionary code to request a balance of fees for any appliances that are in situ when you take over treatment. Add observations detailing the treatment still to be completed and include any new items of treatment. We will return the submitted prior approval claim as an information request so you can upload relevant evidence for the case, including records and the original OPT if supplied by the original practitioner. If approved, you will receive the 30-digit approval reference and balance fees for the completion of treatment and any new items of treatment. When you have completed all treatment, submit a final payment for any treatment you started and finished, along with code 3861 01 and the balance of fees we returned.