Health First Colorado Orthodontics (Criteria for Orthodontics — Children 20 and Younger)
Customize your policy alerts
Sign up for all dentaquestdental policy alerts
Know when dentaquestdental releases new policies or updates existing guidance.
Monitor payer policy activity
Defines medical necessity, prior authorization, billing, and coverage rules for orthodontic treatment for Health First Colorado members age 20 and younger, including documentation requirements, covered/ noncovered codes, continuation/transfer of care, and payment rules.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial Orthodontic Treatment (Children 20 and younger)
Covered when ALL of the following are met:
Supported by eligibility statement
PAR and documentation used to determine medical necessity per Colorado criteria and EPSDT rules
Appendix A forms determine qualification
Reimbursement/Service Limits During Treatment
Once PAR approved, care is inclusive in case rate
D8670 may be billed same day as D8680; D8680 corresponds to de-banding date
Continuation and Transfer of Care (COC/TOC)
Original provider should maintain patient until DentaQuest confirms PAR approval for new provider
Approved PARs for transfer considered per requirements
Case-rate divided by 24 months for cases completed within 24 months; full case rate for cases past 24 months when medical necessity met
Orthodontic treatment that is performed primarily for cosmetic reasons or when self‑esteem is the primary rationale is not a covered benefit. Providers must use the Colorado Orthodontic Criteria Index Forms and supporting records to document medical necessity; cases that do not meet the qualifying criteria on those forms are not eligible for coverage. (See EPSDT considerations for concurrent medical conditions.)
DentaQuest does not separately reimburse for repair or replacement of routine orthodontic items such as bands, brackets, wires, headgear, or other devices normally associated with routine orthodontic care. Additionally, providers may not balance‑bill members for cosmetic service upgrades (for example, clear bracket/aligner systems) beyond the payment provided by Health First Colorado.
Orthodontic services are not a benefit when the member does not have a severe handicapping malocclusion. Coverage is limited to cases that meet the qualifying criteria on the Colorado Orthodontic Criteria Index Form(s); mild or moderate malocclusions without a concurrent medical condition do not meet medical necessity for orthodontic treatment under this program.
Coding and Billing
| D8030 | Not covered orthodontic code |
| D8040 | Not covered orthodontic code |
| D8660 | Initial orthodontic examination |
| D0120 | Periodic oral evaluation |
| D0140 | Limited oral evaluation |
| D0150 | Comprehensive oral evaluation |
| D0160 | Detailed and extensive oral evaluation |
| D0170 | Re-evaluation – limited, problem-focused |
| D8070 | Comprehensive orthodontic treatment of the transitional dentition |
| D8080 | Comprehensive orthodontic treatment of the adolescent dentition |
Provider Actions and Requirements
Obtain PAR with full work-up and ADA claim form
Prior authorization (PAR) is required to determine severe handicapping malocclusion and to approve orthodontic case services; providers must submit the current ADA claim form for PARs and include Colorado Orthodontic Criteria Index Form(s) and required radiographs/models/photos. An approved PAR includes span dates that must cover the dates of service for reimbursement.
- Submit current ADA claim form with PAR.
- Include Colorado Orthodontic Criteria Index Form(s) and required radiographs/models/photos to document severe handicapping malocclusion.
- Ensure approved PAR span dates cover planned dates of service.
Do not balance-bill for cosmetic upgrades
Providers may not balance-bill members for additional services, supplies, or cosmetic upgrades (including clear bracket/aligner systems such as Invisalign); claims payment is considered payment in full and such upgrades are not separately reimbursable by Health First Colorado.
- Do not charge members for cosmetic service upgrades beyond Health First Colorado allowances.
- Clear bracket/aligner systems are explicitly listed as cosmetic upgrades not paid.
Include full work-up documentation with PAR
Providers must include the Colorado Orthodontic Criteria Index Form(s) and the required work-up documentation with PARs: lateral cephalometric and panoramic radiographs, plus study models or Ortho Cad equivalent or the specified diagnostic photographs.
- Required: Colorado Orthodontic Criteria Index Form(s).
- Required radiographs: lateral cephalometric and panoramic radiographs.
- Required records: study models or Ortho Cad equivalent or appropriate photographs (frontal in occlusion straight-on and low angle; right and left buccal in occlusion; maxillary and mandibular occlusal views).
Accepting photos of study models as alternatives
DentaQuest will accept quality photographs of study models in lieu of some photographic requirements when submitting a PAR, per the PAR instructions.
- Quality photographs of study models may be submitted instead of some required clinical photographs as allowed in the PAR instructions.
Ensure treatment dates fall within approved PAR span
Claims with dates of service outside the approved PAR span dates will not be reimbursed; if treatment start is delayed past the PAR end date or a PAR lapses, the provider must submit a new PAR before beginning treatment.
- Verify the PAR effective start and end (span) dates and ensure claims' dates of service fall within them.
- If the approved PAR end date passes before treatment begins, obtain and approve a new PAR prior to starting care.
Confirm orthodontic specialty enrollment before providing services
Only providers enrolled with an orthodontic specialty designation are eligible for reimbursement; providers will not be paid for orthodontic services until they are enrolled by the Department as an orthodontic specialist.
- Confirm orthodontic specialty enrollment and credentialing before rendering orthodontic services to Health First Colorado members.
Background
The purpose of the orthodontic benefit under Health First Colorado is to provide treatment only for members who have a severe handicapping malocclusion as determined by the Colorado Orthodontic Criteria Index Form(s) and the required supporting radiographs and records. Prior authorization (PAR) using the ADA claim form and submission of the Index Form(s), lateral cephalometric and panoramic radiographs, and study models or acceptable photographs is required to establish medical necessity and authorize a case.
Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.