The ultimate dental insurance verification checklist for higher claim acceptance and revenue

8 minute read

Dental insurance verification is a step in the revenue cycle that is often skipped, rushed or forgotten, which leads to dental insurance claim denials — and then delays in your cash flow. Use our insurance verification checklist to make sure you have everything you need for accurate insurance claim submissions that help get you paid promptly.

Dental insurance verification is how your team ensures they have all the accurate information needed to submit clean claims for a patient. But if they skip this step, rush through it, or get it wrong, incorrect information will lead to immediate claim denials.

This leads to more work for your team: tracking down the right information, filing claim appeals, and following up until payment is made.

The result? Delayed payments that slow your cash flow, and can even affect your bottom line. This is why it’s so important to do dental insurance verification with care for every appointment — to submit claims right the first time.

But we get it: Gathering the details is tedious, and it can be time-consuming if a patient’s insurance has changed. That’s why we’re here to make it easier for you!

We’re sharing our ultimate dental insurance verification checklist that will help you submit clean claims and collect more revenue with fewer delays.

Key takeaways on dental insurance verification:

Always perform verification at least 2 or 3 days before your patient’s appointment
Every detail matters when verifying insurance and submitting claims
Mistakes with insurance verification at the start lead to costly delays in the end

Prep Step: Do you even need to do insurance verification?

Short answer? Yes!

Long answer: Yes, and you’ll be happy you did. You’ll submit accurate claims, and it will be easier to calculate an accurate out-of-pocket estimate when you know the patient’s current insurance coverage details.

When a new patient calls for an appointment, be sure to get the whole outline of their insurance plan. If they’re a recurring patient, be sure to check whether their insurance or personal information have changed.

You should also be sure to perform this insurance verification 2 or 3 days prior to patients’ appointments. This gives you time to follow up with them if you need to clarify or get additional information without adding time to their appointment.

Now let’s get into what you need to properly verify dental patients’ insurance coverage.

Step #1: Determine if the dental patient is eligible for insurance benefits

The first question to ask: Are this patient’s benefits up to date and active? To answer this question, you’ll pull up their insurance company’s portal and look for their coverage details.

Here’s your step-by-step list on what to look for when determining eligibility:

FIRST: Find the effective date of their benefits. This lists when the patient's benefits go into effect. If they just got a new insurance plan, there’s a chance their benefits have not gone into effect yet.
Check their plan maximum. The patient’s insurance maximum is the total amount of money the insurance provider will pay for their dental care within a 12-month period. You will need to see if they are close to reaching their maximum. When the patient exceeds their maximum, they will have to pay more out of pocket, and that will impact your cost estimate.
Determine their typical coverage percentages. Both you and the patient should understand how much of the planned procedure their insurance will actually cover. The coverage percentages from insurance are typically 100%, 80%, or 50%, and the patient will pay the remainder (0%, 20%, or 50%, respectively).
Figure out the patient’s deductible. A deductible is the predetermined amount of money a patient pays out-of-pocket for their dental expenses before the insurance company will start paying the plan’s benefits. Like their insurance maximum and coverage percentages, the patient’s deductible can affect how much they are responsible for paying. Most plans include per person and family deductibles that “reset” on the first of the year.
Check for any benefits already used. Has the patient already used up their yearly benefits for this procedure? If so, inform the patient and schedule their treatment for a time after their insurance has renewed for the coming year. Obviously, this depends on the urgency of the procedure, but offer the patient their options, including what it will cost to pay entirely out of pocket.

Once you know where your patient’s insurance benefits eligibility status stands, you must dive deeper into the specifics of their actual insurance plan — especially because these are details most patients won’t look for or understand when reviewing their coverage documents.

Step #2. Evaluate the patient’s dental insurance exclusions and clauses

Exclusions and clauses refer to the rules and conditions of the patient’s insurance plan contract. This is the small print you don’t want to miss, as it greatly impacts how the patient will be covered by their benefits and, with that, their out-of-pocket costs. Many exclusions and clauses depend on timing, as you’ll see.

Here are conditions you need to verify during insurance verification:

Frequency. A dental insurance plan can limit the number of times it will pay for a certain treatment within the plan period. For example, the patient’s plan may only pay for two cleanings a year.
Age limitation. A patient age 26 or older cannot usually be covered under their parent’s insurance plan — it depends on the specifics of that plan. There are age limits for specific procedures, too. For example, patients can typically be covered for fluoride up to age 16 and receive orthodontic benefits up to age 18.
Replacement clause. This stipulates that the insurance company will not pay for a replacement for certain dental procedures — such as a lost retainer or a filling —within 24 months of the original placement date. For example, if your patient received a bridge four months ago, and it needs to be replaced, their insurance plan may not cover a replacement for 5 to 10 years from the original procedure.
Missing tooth clause. If the patient lost the tooth before their insurance began, the insurance will not cover the treatment to replace the missing tooth. However, if the employer has a new plan only because their employer switched to a new insurance carrier, then that claim denial should be appealed.
Waiting periods. If the patient recently enrolled in a new insurance plan, there might be a waiting period that prevents them from benefiting from their insurance coverage. It may be months or years before certain dental procedures will be covered for that patient. This is usually for restorative or major dentistry.
Downgrades. A downgrade is when insurance plans will only pay for the least expensive procedure if there is more than one acceptable option. If there is a less expensive option for treatment, it’s a legal requirement that you inform your patient.

Pro tips from our billing experts

Now you know what to look for during insurance verification. And for even greater success, we’re sharing 2 additional pro tips we’ve learned by being a dental revenue cycle management solution since 2012.

Insurance verification for families: Not everyone’s coverage is the same

Family members who are covered by the same insurance plan will not have identical benefits summaries, because the amount of money each person has spent toward their individual deductibles and coverage maximums will vary. However, the coverage percentages and exclusions will be the same for all members of the family.

Confirm outstanding claims: Avoid underestimating dental care costs

Patients who share the same group number will usually have the same coverage, but as with family members, remember to check the deductible and remainder of their maximum amount, as they will certainly vary from person to person.

This is especially important if the patient was referred for specialty dentistry, or if you are the specialist they were referred to. Verify with the general dentist to make sure there are no claims outstanding, or your cost estimates will be too low.

You may lose your patient’s goodwill and damage the patient relationship if they receive a bill that’s significantly higher than the estimate you initially presented — particularly if they weren’t expecting a bill at all. So, be sure to update the remaining deductible and maximum in your practice management software to ensure accurate estimates.

Verify dental insurance confidently with this checklist at your side

To recap:

Be prepared: Perform insurance verification 2 or 3 days in advance
Step 1: Determine if the dental patient is eligible for insurance benefits
Step 2: Evaluate the patient’s dental insurance exclusions and clauses
Pro Tip #1: Family members accrue deductibles and maximums at a different rate even when they’re on the same plan
Pro Tip #2: Always confirm outstanding claims for accurate dental care cost estimates

Insurance verification is a crucial step at the start of the revenue cycle which sets the stage for easy collections from both patients and insurance. Small mistakes cause big problems: The wrong birthdate or a missed coverage limitation can lead to a denied claim and unexpected out-of-pockets costs for your patient.

That’s why it’s so important to get this step right. If you don’t take the time in the beginning, you’ll have to make time for it at the end — resubmitting appeals, repairing a damaged patient relationship, and perhaps writing off a patient’s disputed balance.

When it comes to your revenue cycle, DCS is here to help from beginning to end. Our full-cycle services include insurance verification, insurance billing, and our fully automated ZeroBalance patient collections software.

Turn to our experts and today’s technology to take all of this billing work off your team’s plate, so they can focus on patient care: Book a free 30-minute consultation today.

Dental revenue resources from Dental Claim Support