Colorado Child Health Plan Plus Orthodontics — Comprehensive Orthodontic Treatment (Child Members 18 and Younger)
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Defines coverage, prior authorization, documentation, billing and provider requirements for comprehensive orthodontic treatment for Colorado Child Health Plan Plus members aged 18 and younger.
Effective July 1, 2026, reimbursement schedule requires payment of one D8070/D8080/D8090 at banding, three D8670 after at least 5 months, and one D8680 at de-banding after at least 18 months.
Coverage Criteria
Comprehensive Orthodontic Treatment (Initial authorization)
Covered when ALL of the following are met
Members are not eligible once they reach age 19 or if enrolled in Prenatal and Cover All Coloradans program.
Orthodontic services that are excluded from coverage include treatment that is primarily cosmetic in nature and clear aligner systems (for example, Invisalign). The policy explicitly lists Invisalign and other clear bracket/aligner systems as cosmetic upgrades that are not covered and therefore are not eligible for prior authorization or reimbursement. (See excluded services list.)
Limited orthodontic procedures billed with CDT codes D8010–D8060 are also not covered. Only comprehensive orthodontic services meeting medical necessity criteria may be authorized and reimbursed, and providers must be enrolled with an orthodontic specialty designation to receive payment for orthodontic services.
Orthodontic treatment is not medically necessary when the condition does not demonstrate severely handicapping labio-lingual deviation. Treatment requests submitted solely for cosmetic reasons or where the member’s primary motivation is self‑esteem do not meet medical necessity and will not be authorized.
Prior authorization may be denied if the member fails to meet program requirements such as having 12 months of continuous CHP+ coverage prior to PAR submission, and authorization will not be granted for cases determined to be primarily cosmetic or lacking the required severity on the Handicapping Labio‑Lingual Deviation Index.
Coding and Billing Rules
| D8070 | Comprehensive orthodontic services (banding) — one allowed per treatment; submit claim on date of banding. |
| D8080 | Comprehensive orthodontic services (alternative banding) — one allowed per treatment; submit claim on date of banding. |
| D8090 | Comprehensive orthodontic services (alternative banding) — one allowed per treatment; submit claim on date of banding. |
| D8670 | Periodic orthodontic treatment visit — up to three payments; may be billed no earlier than 5 months after banding; may be billed on same day as D8680. |
| D8680 | Orthodontic retention (de-banding) — one payment at de-banding/retention; submission must correspond to date of de-banding and be at least 18 months after banding. |
| D8010 | Limited orthodontic treatment — not covered. |
| D8020 | Limited orthodontic treatment — not covered. |
| D8030 | Limited orthodontic treatment — not covered. |
| D8040 | Limited orthodontic treatment — not covered. |
| D8050 | Limited orthodontic treatment — not covered. |
| D8060 | Limited orthodontic treatment — not covered. |
| Invisalign | Clear aligner systems (Invisalign) — not covered (cosmetic upgrade). |
| D8070/D8080/D8090 | Only one of these codes will be reimbursed at banding per comprehensive treatment; submit on date of banding. |
| D8670 (x3) | Providers will be reimbursed up to three D8670s on dates of service no earlier than 5 months after banding. |
| D8680 (x1) | Providers will be reimbursed one D8680 at de-banding/retention no earlier than 18 months after banding; D8670 may be billed same day as D8680. |
Provider Actions, Prior Authorization & Documentation
Prior authorization required for comprehensive orthodontics (CHP+ ≤18)
Comprehensive orthodontic treatment for Child Health Plan Plus (CHP+) members age 18 and younger requires prior authorization based on the Handicapping Labio-Lingual Deviation criteria; approved PARs include span dates and are valid for 1080 days but never beyond the member’s 19th birthday.
- Prior authorization is required for comprehensive orthodontic treatment for CHP+ members age ≤18.
- Approved PARs include effective span dates; PARs are valid for 1080 days and will not be valid after the member turns 19.
Provider obligations for orthodontic PARs and reimbursement
Providers must be enrolled with an orthodontic specialty designation to provide and be reimbursed for orthodontic services; use the PAR process and submit required documentation as outlined in the policy.
- Only dental providers enrolled with an orthodontic orthodontic specialty designation are allowed to provide orthodontic treatment and be reimbursed.
- Submit prior authorization requests and follow standard DentaQuest processes for notifications and appeals.
Required documentation to include with PAR
Submit the complete work-up with the PAR: Handicapping Labio-Lingual Deviation (HL-LD) Index Score Sheet, lateral cephalometric radiograph, panoramic radiograph, study models or OrthoCad equivalent or appropriate photographs, and the specified photographic views.
- Handicapping Labio-Lingual Deviation Index Score Sheet (Appendix A)
- Lateral cephalometric radiograph
- Panoramic radiograph
- Study models or OrthoCad equivalent or acceptable photographs
- Photographic views: frontal in occlusion straight-on, frontal in occlusion low angle, right buccal in occlusion, left buccal in occlusion, maxillary occlusal view, mandibular occlusal view (or quality model photographs meeting the listed parameters)
Use current ADA Dental Claim Form for PARs and claims
The current ADA Dental Claim Form must be used for all prior authorization requests and claims submissions for orthodontic services.
- Use the current ADA Dental Claim Form for PARs and for claims related to orthodontic services.
PAR may be denied for insufficient continuous CHP+ coverage
Prior authorization may be denied if the member does not have 12 months of continuous CHP+ coverage prior to PAR submission; verify coverage through the HCPF Portal and follow the DentaQuest appeal process if verification shows continuous coverage.
- Members must have 12 months of continuous coverage under the CHP+ program prior to PAR submission.
- If HCPF Portal verification shows 12 months of continuous coverage and the member was active, follow the DentaQuest standard appeal process for denials.
Authorization denied for cosmetic or non-severe HL-LD cases and excluded services
Authorization will not be granted for orthodontic treatment that is primarily cosmetic, for cases that do not meet the severe Handicapping Labio-Lingual Deviation criteria, or for excluded services such as Invisalign and limited orthodontic codes D8010–D8060.
- Orthodontic treatment primarily cosmetic in nature is not covered.
- Treatment that does not demonstrate severe handicapping labio-lingual deviation per the HL-LD Index is not eligible for authorization.
- Excluded services include Invisalign/clear aligner systems and limited orthodontic treatment codes D8010–D8060.
Background
Coverage for comprehensive orthodontic treatment is limited to child members who demonstrate severe handicapping labio‑lingual deviation as determined by the Handicapping Labio‑Lingual Deviation Index Score Sheet. The index is used to establish medical necessity; if the index does not indicate severe handicapping deviation, orthodontic services are considered not medically necessary.
This limitation reflects the policy’s intent to cover orthodontics only when functional impairment meets a standardized severity threshold rather than for cosmetic reasons. Providers must document the index score and supporting diagnostic records with the prior authorization request to demonstrate eligibility.
Definitions
Revision History
Reimbursement and billing timing for comprehensive orthodontic treatment updated to allow one D8070/D8080/D8090 at banding, up to three D8670 paid no earlier than 5 months after banding, and one D8680 at de-banding paid no earlier than 18 months after banding; limits total payments during a comprehensive treatment to these amounts.
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