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Health care criteria for medically necessary orthodontia

Essential Health Benefits (EHB) orthodontic forms must be completed for all EHB orthodontic claim submissions.

  • Please select the appropriate state form specific to the subscriber’s group state of issue and plan name shown on the member’s ID card
  • Fill out the applicable form in full, attach required documentation, and submit with completed dental claim form for review of medical necessity
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  • No required form

  • No required form

  • No required form