Resources for dental offices
Verifying dental insurance might not be the most exciting part of the day, but it’s one of the most important. Without a solid process, small mistakes can lead to claim denials, billing headaches, and frustrated patients. The good news is it doesn’t have to be complicated. With a simple checklist, you and your team can save time, avoid confusion, and keep the schedule running smoothly. Let’s break it down into manageable steps anyone at the front desk can follow.
May 1, 2025
1. Collect Core Patient Information
Accurate patient data is the foundation of insurance verification. Missing or incorrect details can delay or prevent claims from being processed.
Full name and date of birth: Use the exact name as it appears on the insurance card; minor spelling differences can trigger rejections. Birth dates must be precise, as even small errors are a common cause of denied claims.
Contact information: Collect multiple contact methods, including mobile and landline numbers, email address, and current mailing address. Having several ways to reach patients helps resolve issues quickly and keep them informed about coverage.
Insurance card details: Capture clear images of both sides of the insurance card and store them digitally. Digital records help reduce input errors during claim submission.
This provides quick access to:
Insurance company name
Policy and group numbers
Policyholder details (if different from the patient)
2. Confirm Policy Information
Verifying policy details ahead of time helps prevent complications during billing.
Insurance provider and contact info: The insurer listed on the card may not be the current carrier. Use provider portals or direct contacts to confirm.
Policy and group numbers. Both are essential; policy numbers identify the individual’s coverage, and group numbers tie the plan to an employer. Group numbers can change with employment updates, so always verify.
Coverage dates: Check that the policy is active on the date of service. Gaps are common at the start of the year or when patients change jobs. Confirm status 2–3 days before appointments to catch any recent changes.
3. Determine Coverage Specifics
When you understand what's covered, it helps you plan treatments accurately and communicate clearly with patients about costs.
Plan type: Identify if your patient has:
PPO (Preferred Provider Organization): More flexible with in-network and out-of-network options, usually with deductibles and coinsurance
HMO (Health Maintenance Organization): Lower premiums but limits patients to network providers, often using copays instead of deductibles
Each type requires different verification steps. For PPOs, check network status, deductible status, and remaining yearly benefits. For HMOs, verify the patient's chosen primary dentist.
Coverage percentages: Check coverage percentages for different procedures:
Preventive care (cleanings, exams): Often 100%
Basic procedures (fillings): Typically 80%
Major procedures (crowns, bridges): Usually 50%
Understand the plan's UCR (Usual, Customary, and Reasonable) fees, as these affect your actual reimbursement.
Annual maximums: Check the maximum amount the insurance will pay each year and track what's left. This matters most toward year-end when patients might be approaching their limits.
4. Identify Limitations and Exclusions
Insurance policies come with fine print that affects treatment options and patient costs. Including this step in your dental insurance verification checklist ensures you catch potential issues early. One such issue is dental insurance downgrades, where the insurance pays for a less expensive procedure than the one that was performed.
Waiting periods: Check if certain procedures have waiting periods. New patients might need to wait 6–12 months before major work gets covered. Verify how long waiting periods last for different procedures, whether the patient has completed applicable waiting periods, and any exceptions that might apply.
Frequency limitations: Insurance plans limit how often they cover certain procedures. The standard is two cleanings per year, X-rays every 3–5 years, and 5–7 years for replacement timeframes for dentures or bridges. Check the patient's history to confirm the planned work fits within these rules.
Age restrictions: Some procedures have age limits for coverage. Sealants are usually just for kids and teens, and fluoride treatments are often capped at certain ages. Check age-specific coverage when you treat young or elderly patients.
Missing tooth clause: This common exclusion means insurance won't cover the replacement of teeth that were missing before the policy started. When checking coverage for implants, bridges, or partials, see if a missing tooth clause exists, identify which teeth might be excluded, and look for exceptions that might override the clause.
5. Confirm Pre-Authorization Requirements
Pre-authorization reduces your risk of denials by confirming coverage before you start treatment.
Procedures Typically Requiring Pre-Authorization
Pay attention to these commonly pre-authorized treatments:
Orthodontic work
Surgical extractions
Periodontal surgeries
Implants and related prosthodontic work
Simplifying the Pre-Authorization Process
To make the pre-authorization process run smoother, try the following:
Use technology: Electronic portals speed up submissions and approvals. Dental software solutions can connect pre-authorization requests with your billing system.
Standardize documentation: Keep detailed records, treatment plans, and supporting documents in a single, central location.
Track performance: Watch approval rates, processing times, and denial reasons to spot areas for improvement.
Pre-authorization requires work upfront but provides security for your practice and clearer cost information for your patients.
6. Communicate with the Patient
Clear communication about insurance builds trust and prevents billing surprises. Learning strategies for communicating with dental patients about insurance can improve patient satisfaction.
Explain coverage details: Use simple language instead of insurance jargon: "Your insurance covers your cleaning completely. For fillings, they cover 80% and you pay 20%. For crowns, they pay half and you pay half."
Provide out-of-pocket estimates: Always give written estimates before treatment. When coverage is limited, offer options: "Based on your insurance, you'll pay about $500 for this crown. We also offer a temporary filling that's fully covered if you'd prefer to delay the crown."
Answer questions thoroughly: Be ready for common questions about:
Why procedures aren't fully covered
How much of their annual maximum remains
Why pre-authorization is needed
Document these conversations to prevent future disputes.
7. Document and Store Verification Information
Good documentation helps resolve disputes and ensures continuity of care, especially in complex situations like the coordination of dental benefits.
Maintain Comprehensive Records
Keep detailed verification records, including:
Insurance verification forms
Benefits summaries
Verification confirmation numbers
Notes from calls with insurance reps
These records prove invaluable when you need to resolve claim issues or answer patient questions.
Update Patient Files Regularly
Keep insurance information current, especially early in the year when plans often change:
Check details at every visit
Update changes in coverage, deductibles, or maximums
Note new exclusions that might affect treatment
Leverage Practice Management Software
Use your software to:
Record when you verified insurance
Set reminders to verify again
Store digital copies of insurance cards
Track insurance changes over time
Having this information in one place creates a reliable resource for your entire team.
8. Regularly Update Verification Processes
Insurance verification needs ongoing refinement. Regularly reviewing your dental insurance verification checklist keeps it relevant and updated.
Stay informed: Insurance companies frequently change policies, add exclusions, or update procedure codes. Keep up with insurance changes by:
Following insurer updates
Attending industry webinars
Joining dental associations
Train staff continuously: Well-trained staff handle complex verification more efficiently. Invest in regular training, such as quarterly updates on insurance trends. Practice handling challenging clients and scenarios, and encourage team members to share their learning experiences.
Review and improve: Regularly assess your verification process by tracking denial rates and verification times, and review workflows quarterly to identify bottlenecks. Other ways to improve processes include incorporating strategies to reduce patient wait times and gathering feedback from staff and patients.
By improving verification workflows, you can improve overall patient satisfaction. This data-driven approach helps you fine-tune your processes.
Adopting this dental insurance verification checklist can help your dental practice reduce claim denials, improving productivity and patient satisfaction. Though verification requires time upfront, it prevents costly problems throughout the billing cycle.
Set Your Practice Up for Success
A solid insurance verification process helps your dental team avoid billing surprises and keeps patients happy. By following this checklist, you can reduce claim denials, improve efficiency, and build trust with your patients.
If you're short-staffed or need extra hands to keep things running smoothly, Teero can help. Teero offers flexible dental staffing solutions, connecting your practice with qualified hygienists and assistants, whether you need temporary coverage or long-term support.
Our platform makes it easy to find reliable professionals and fill shifts quickly, so your team can stay focused on delivering great patient care. Contact us to learn more.