Dental insurance verification

Who dreads the statement “I have new dental insurance. What does my new plan cover?” Better yet, when a patient lets you know at the end of their appointment, they now have dental insurance. Now we need to know exactly what’s covered for their appointment they just had.

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All dental plans are not created equal. When checking dental benefits for patients, especially when it’s a last-minute dental insurance verification there are many things that can get missed. A few of the biggest mistakes could possibly damage the dental practice’s relationship with patients.

Nine times out of ten, insurance companies are downgrading procedures.

Waiting Periods

It seems that more and more dental insurance companies are having waiting periods on more procedures these days. If waiting periods aren’t asked while verifying, a lot of insurance companies don’t always divulge this information. I was checking an insurance recently and there was a six-month waiting period on a full mouth series of x-rays.


Nine times out of ten, insurance companies are downgrading procedures. Most of their downgrades seem to be on restorative work. Resin fillings are usually paid out at an amalgam rate.

As an example, let us assume it’s $140 for white resin filling. The insurance downgrades this to a silver amalgam fee of $100. Therefore, the insurance pays 80% of $100 (silver amalgam fee), which is $80. Patient pays $28 copay (20%), plus difference in filling type of $32. Total patient cost = $60 for the filling.

I’ve also seen where they downgrade on all porcelain crowns. One insurance downgraded an implant to a partial denture, even though implants were a covered benefit under their plan.

Missing Tooth Clause

Do you have a patient that gets insurance because they had an extraction and now need an implant? They get new insurance that has implant coverage, only to find out there’s a missing tooth clause. Then they are frustrated and never knew the questions to ask their own insurance company before signing up. More than 90 percent of insurance companies have a “missing tooth clause” or a “replacement clause.” Many include at least one of these, but most have both. A missing tooth clause protects the insurance company from paying for the replacement of a tooth that was missing before the policy was in effect.

Non-Dup or Non-Dual

What happens when there’s a primary and a secondary insurance? Things always get a little trickier. With secondary insurance you always need to ask if they have non duplicate or non- dual. Non duplicate is one that probably gets missed and can really alter a patient’s treatment plan and their out of pocket cost. What is non duplicate? If the primary insurance paid 70 percent and the secondary insurance covers 70 percent as well; the secondary insurance would not make an additional payment. However, if the primary insurance had only paid 60 percent, the secondary insurance would pay the remaining 10 percent.


Limitations may be related to time or frequency. For example, no more than two cleanings in a calendar year or one cleaning every six months. Insurance companies have frequencies set so a patient can’t have 12 exams in a year.

For example, no more than two cleanings in a calendar year or one cleaning every six months. Insurance companies have frequencies set so a patient can’t have 12 exams in a year.

They will sometimes have stipulations of what procedures can be done together at one visit. Example, if a patient needs scaling and root planning most insurances won’t allow more then 2 quads in a single visit.

Just remember when checking benefits for patients to take your time, ask all the right questions, and if you aren’t confident in their insurance always send in a pre-authorization. Patients will appreciate you caring enough to make sure their treatment plans are not just a guessed estimate or an actual estimate.

Tegan Conger

Tegan Conger has been in the dental field since 2003. She has a strong passion for the dental community. She exercises her expertise in helping patients understand their treatment needs and with all aspects of their insurance. . Growing practices and creating a larger patient base is always something she continues to strive for in any office she works in. She also enjoys attending CE course that help her dental insight expand.

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