How to Verify Dental Insurance: A Step-by-Step Guide

What You Need Before You Start

Have the patient’s and the subscriber’s details in front of you, exactly as the payer has them: both names and dates of birth, the patient’s relationship to the subscriber, and the member ID. Add the payer, the employer or group name, the group number and the payer ID, and the appointment date.

Then work through the five steps below in order. They follow the seventeen numbered checks on our free dental insurance verification form, so each answer has a place to go.

Step 1: Confirm Eligibility, Dates and Waiting Periods

Start with whether the plan is active on the day of the visit. Record the date coverage starts, which the ADA calls the eligibility or effective date, and any end date.^*

Note the plan year as well. Maximums and deductibles run on the plan’s benefit year, which may or may not be the calendar year.^*

Ask about waiting periods: the time between enrollment and when a benefit becomes available, category by category.^* And ask whether the patient has other coverage. Coordination of benefits sets how two plans share the cost; for a child covered by both parents, the most common rule is the birthday rule, where the plan of the parent whose birthday comes first in the calendar year pays first, unless something like a court order says otherwise.^*

On the form: checks 1 to 4.

Step 2: Record the Maximum, the Deductible and Coverage

Many plans cap what they pay each year.^* Write down the annual maximum, how much has been used and how much remains, before anyone quotes a treatment plan.

Then the deductible: what the patient pays before the plan pays, for the individual and the family, how much has been met, and which categories it applies to.^*

Last, coverage by category: the percentage the plan pays (coinsurance) in preventive, basic and major, and where endodontics, periodontics and oral surgery fall.^*

On the form: checks 5 to 7.

Step 3: Check Frequencies, History and Age Limits

Ask how often the plan pays for exams, cleanings, bitewings, a full series or panoramic x-ray, fluoride and sealants, and whether any of them has an age limit.^* Then ask for the last date of each, and of any periodontal treatment, so you know whether the visit falls inside a frequency limit.

Ask whether anything changes at 19. Age is one of the limitations a plan can set, and in the Health Insurance Marketplace, dental coverage is an essential health benefit for children 18 and younger but not for adults.^* Where the plan pays differently at 19, record both: the maximum, deductible, coverage, exams and cleanings, fluoride and sealants.

On the form: checks 8 to 10, with the CDT code for each service.

Step 4: Ask About the Limits That Change a Treatment Plan

These are the answers that decide what a patient will owe for bigger treatment. Ask about each one before you present a plan.

• Missing tooth clause. Some plans restrict coverage for conditions present before enrollment, such as missing teeth.^* Ask before planning a bridge, implant or denture.
• Downgrades. Under an alternate benefit clause, the plan bases its payment on a less expensive procedure, for example a composite filling on a back tooth paid at the amalgam rate.^* Ask which procedures it applies to.
• Orthodontics. Who the plan covers (children only, and to what age, or adults too), the percentage, the lifetime maximum and how much of it is used, any ortho deductible or waiting period, and whether it pays in a lump sum or in installments.
• Implants. Whether the plan covers implants and at what percentage, and which parts it pays for: the implant body (D6010), the abutment (D6056 or D6057) and the crown.
• Night guards. Whether the plan covers an occlusal guard, and which kind: D9944 (hard, full arch), D9945 (soft, full arch) or D9946 (hard, partial arch).^*
• Pre-authorization. Which procedures the payer wants to review first. A predetermination sends the treatment plan to the payer before treatment begins and can clarify what the patient will owe.^*

On the form: checks 11 to 16.

Step 5: Write Down the Call Reference

Record who you spoke to, the date and time and the reference number, or the portal page you checked and the date. If the claim pays differently, it’s your record of what you were told.

On the form: check 17.

Portal, Phone or Real-Time Eligibility

Each of the three ways fills in the same form. What differs is where the answers come from and how much of the form they cover.

Payer Portal

Many payers run their own provider portal for eligibility and benefits.^* Each portal is laid out differently and needs its own login, and what you find has to be typed back into your practice software.^* Write down the page you checked and the date.

Phone

Calling takes longer, but some offices consider it the most reliable way to get accurate, complete answers when electronic responses fall short.^* In a 2021 review for the ADA, every payer interviewed said eligibility and benefits calls were its number one call type, and some limit how many checks you can ask for per call.^* Write down the representative, the date and time, and the reference number.

For the call itself, use our free insurance verification phone script.

Real-Time Eligibility

The HIPAA standard eligibility inquiry and response (X12 270/271) goes from your practice management system to the payer, often through a clearinghouse, and stays inside your workflow.^* How much comes back varies by payer: the same review found some answer with a simple yes or no, and the 25 largest payers by claims volume returned, on average, less than half of the recommended response elements.^* Note which checks came back and which still need a portal or a call.

A check mark that only means “the plan is active” can still leave the maximum, frequencies and waiting periods blank.^*

When to Verify, and How Often

Before every visit, early enough to reach the patient if something has changed. That includes returning patients: coverage can change between visits, with a new employer, a new plan or a maximum that has been used up, and maximums and deductibles run on the plan’s benefit year, which may or may not be the calendar year.^*

Use the Free Verification Form

Our free dental insurance verification form puts all seventeen checks on two printable US Letter pages, numbered in the order above, with a frequency table that lists the CDT procedure codes, benefits under and over 19 side by side, ortho, implant and night guard benefits, and a box for the call reference. Print a stack for the front desk and fill one in per patient.

Where CarifyOne Fits

Rather not fill it in by hand? CarifyOne checks eligibility in real time at booking, at check-in, and on demand from the patient profile, and runs the week-ahead verification pass for everyone on next week’s schedule. Verified or not verified: your team always knows which is which. Real-time eligibility checks are on Starter; Carify Verify with unlimited eligibility checks is on Growth. See insurance and claims.

Frequently Asked Questions