Dental insurance verification checklist

Plan basics

• Payer, plan name and group number
• Subscriber details and the patient's relationship to them
• Effective date, and whether the plan is currently active
• Benefit year — calendar or plan year, which changes when maximums reset

Money

• Annual maximum, and how much remains
• Deductible, whether it has been met, and whether it applies to preventive
• Coverage percentages by category — preventive, basic, major
• Whether the plan pays on UCR, a fee schedule, or a table of allowances

The fields that cause denials

• Frequencies: exams, prophy, bitewings, FMX, perio maintenance
• History — what has already been used this benefit period, confirmed with the payer rather than assumed from your ledger
• Waiting periods by category, especially on major work
• Downgrades and alternate benefit provisions (posterior composite to amalgam being the common one)
• Missing-tooth clause and replacement intervals for prosthetics
• Age limits — sealants, fluoride, orthodontics

Administrative

• Claims mailing address or payer ID
• Whether pre-authorisation is required, and for which categories
• Timely filing limit
• Whether the practice is in-network for this specific plan, not just this payer

Where it goes

Into the patient's record in your practice management system, not into an email. The test: can the treatment coordinator open the patient and see verified numbers without asking anyone? If not, the verification has not really happened.

When to re-verify

• At the benefit year boundary
• For any patient not seen in the last twelve months
• Before any significant treatment plan is presented
• Any time the patient mentions a job change