Dental Insurance Eligibility Challenges
Insurance Verification and Eligibility Challenges
Let’s be real—insurance verification is probably my least favorite topic, and I have a strong feeling you might feel the same way. It’s tedious, time-consuming, and let’s face it, a thankless task. But it’s also an essential part of running a smooth and profitable dental practice.
This is my personal guide on how I like to implement insurance verifications and eligibility processes in the offices I work with. Before diving in, I want to emphasize something important: Every office is different, and what works for one may not work for another.
A Quick Reality Check
At the end of the day, insurance verification is a courtesy we provide to patients. While thorough verification benefits both the practice and the patient, it’s ultimately the patient’s responsibility to know their own benefits. This perspective can save your team frustration and help keep priorities aligned.
There are some amazing companies out there that specialize in insurance verification services. While Elite Dental Systems doesn’t currently offer these services, I have developed a guide that I recommend offices follow for an efficient and streamlined process.
In this article, I’ll share some quick tips for managing verifications for PPO, HMO, and Medi-Cal plans, and highlight scenarios where you should ask for medical insurance information. Remember, there’s no one-size-fits-all solution—take what works for you and leave the rest.
Streamlining PPO Verifications
Annual Blueprints: For PPO plans, ensure you have an up-to-date insurance breakdown (“blueprint”) for each group. This prevents double work when verifying benefits for multiple patients under the same plan.
Quick Online Checks: Use your office’s preferred online portals to confirm eligibility and real time basic benefits like maximums, deductibles, and frequencies. Call the insurance provider only for missing or unclear details when filling out your full breakdown.
Know Your Codes: Verify that the plan covers the specific CDT codes your doctor uses, especially for procedures like SRPs, crowns, or implants, to avoid surprises when submitting claims.
PPO New Patient Full Breakdown: Verifying a New Plan and Setting Up the Patient Chart
When onboarding a new patient, a complete insurance verification sets the foundation for a successful billing cycle. Here’s how to do it right:
Access the Blueprint: Gather all details through the online portal or by fax, covering specific codes the doctor will use. Scan the physical document “blueprint” provided by the patient's insurance company to the patient's chart. Do this ONCE A YEAR for the lifetime of the patient having that plan in your office.
Create an Insurance Breakdown Form: Fill out the breakdown form with any specific code details from the insurance “blueprint”or through online portal and call the insurer for any missing information. This ensures that any applicable limitations or exclusions are identified early.
Treatment History Documentation: For new patients, confirm treatment history details like the date of the last full-mouth X-ray, cleaning, and any history of periodontal scaling and root planing (SRP).
Chart and Appointment Setup: Create the insurance plan in the PMS before the visit, make essential notes directly on the new patient’s appointment (e.g., deductible met, benefit limits on X-rays). When the patient arrives, final setup becomes a simple, seamless process.
PPO Existing Patient: Same Insurance Verification
For existing patients with no change to their insurance plan, verification should be a quick, streamlined check:
Quick Eligibility Confirmation: Use tools available in your PMS like “E-Central” (in dentrix), fax or online portals to confirm that the plan remains active, saving eligibility details in the patient’s file. Confirm the group number and annual max is the same, update any changes at this time. Max could change if the patient was referred to an outside specialist and this number needs to match what is in the system. Verifying is the first step, it is also important to make sure to update any changes at this time.
Annual Blueprint Verification: Ensure that the existing plan has a current-year blueprint breakdown and full breakdown is in the system. If updates or notes are required (such as remaining maximums or deductibles), log this in the patient’s record to avoid surprises at future visits.
QUICK: Do not take too much time checking existing patient's insurance, if the blueprint and FBD is already in the system the practice just simply needs to “confirm” and move on to the next task. Come up with a system so you know it was checked and move to the next patient.
PPO Existing Patient: New Insurance Verification
When an existing patient switches insurance, a more detailed process is required to align the new plan with their treatment history:
New Blueprint and Insurance Entry: Go through the same steps as with a new patient—gather a full insurance breakdown and document the new plan thoroughly.
Treatment and Benefit Updates: Assess any waiting periods, exclusions, or limitations that could impact the patient's existing treatment plan.
PPO New Patient Limited Exam: Emergency or Last-Minute Add-Ons
For emergency or last-minute new patient appointments, a full insurance breakdown may not be necessary. Here’s how to handle these situations:
Quick Plan Verification: Verify the patient’s eligibility and ensure the doctor’s primary codes are covered.
Basic Insurance Information: Make note of any deductibles or used benefits in the appointment notes to guide the billing team.
Efficient Handling: Since these visits are often focused on immediate concerns, such as pain relief, only critical verification is completed, helping the team keep the process smooth and efficient. Focus on patient care!
Streamlining HMO Verification
Roster Checks: HMO verification revolves around confirming if a patient is listed on your roster. This should be done as soon as the appointment is scheduled.
Assignment Requests: If a patient isn’t on the roster but wants to be treated, guide them through requesting an assignment or immediate transfer with their plan provider.
Portal Documentation: Document all roster verifications directly into the patient’s appointment notes or save the confirmation to their chart for future reference.
HMO New Patient
Verifying HMO Roster
Check the roster for all HMO plans when scheduling the new patient visit and confirm they are listed. You can do this after you get the patient on the schedule, or before it is your preference. If the patient isn’t listed, they may need to request an assignment. For emergencies, they can request an immediate transfer.
New Patient Appointment Notes
Document roster information in the appointment note and attach the correct HMO plan once the patient checks in and the chart is created.
HMO Existing Patient
Verifying HMO Roster
Before the appointment, log into the portal, request a fax, or call the insurance to ensure the patient is on the HMO roster. Notate on the appointment its been checked and move onto next patient.
Streamlining Medi-Cal Verifications
Eligibility Fluctuations: Always verify Medi-Cal eligibility for every appointment. Eligibility often changes, and you don’t want to waste chair time on ineligible claims. Document EVC # for every single visit.
Aid Code Accuracy: Ensure that you’re billing under the correct Medi-Cal Aid Code. If you’re unsure, verify the code and update your system to avoid billing errors.
Notice Of Authorizations (NOA’s): For complex treatment plans, confirm whether pre-authorization is required. If it is, attach approval documentation to the patient’s file in your practice management software. Do not proceed with treatment unless this is received by Medi-Cal.
Medi-Cal New Patient
Verifying Medi-Cal Plan
Verify eligibility immediately while on the phone. Obtain the patient’s Member ID, DOB, and name, and confirm acceptance with the office. Document the verification for appointment scheduling. Also, verify the DAY OF APPOINTMENT to confirm no changes.
New Patient Appointment Documentation
Copy eligibility info to the appointment note, and save any screenshots in the “denti-cal patients” folder. Create the patient chart and attach Denti-Cal info only once the patient checks in.
Treatment History
Document treatment history, including past cleanings and fluoride treatments. If benefits don’t cover these, make a note on the appointment. Screenshot or print treatment history from the online portal and save it to the patient's chart for future access.
Entering Insurance into PMS
Use Insurance Maintenance in your PMS to find Denti-Cal with the correct AID CODE. If the correct plan isn’t in the system, edit an existing plan to reflect it with the proper AID CODE and save it as a new plan that way all important insurance specifics will be transferred over and you don't have to make a new one from scratch.
Medi-Cal Existing Patient
Verifying Medi-Cal Plan
Confirm eligibility status online and save a screenshot to the patient’s document center. Notate EVC# for every single visit. Confirm the day before or the day of the visit, each time patients are seen.
Scheduled Treatment Eligibility
Double-check online eligibility and ensure notice of authorizations (NOA’s) are in place if required.
PPO, HMO, and Medi-Cal Simplified
PPO Plans: Verify active PPO plans annually and ensure that the group plan details align with the patient’s treatment needs. Keep up-to-date yearly “blueprints” for accurate yearly verification.
HMO Plans: Check the patient’s roster status with HMO providers like Delta Care and UNUM. If a patient requires emergency care and isn’t on the roster, they may need to request an immediate transfer, ensuring they’re covered at the time of service. Typically eligibility is active at the beginning of the following month if not a true dental emergency.
Medi-Cal (Denti-Cal) Plans: Confirm eligibility at every visit the day of or the day before since Medi-Cal policies frequently change. For treatment planning, check any pre-authorizations or limits on routine and specialized care. Ensure that Medi-Cal Aid Codes are correct, as eligibility is dependent on these specifics.
When to Ask for Medical Insurance Information
In certain cases, dental treatments—such as TMJ appliances, oral surgery, or sleep apnea devices—may be partially or fully covered under medical insurance. Consider requesting medical insurance details if:
The treatment is related to an accident or injury.
The procedure falls under the scope of medical necessity, such as biopsies or certain extractions.
The patient is pursuing sleep apnea treatment, which often involves a referral to their medical insurance.
PRO TIP: Create a system that works with your office to gather the patient’s medical insurance. Make it part of the New Patient Protocol to ask for medical insurance AND dental insurance at check in and scan both cards in the patient chart so that if medical insurance information is needed for future you already have the information.
Educating your team on identifying these scenarios can help patients save money while opening additional revenue streams for your practice.
Key Takeaways
Insurance verification and eligibility might not be glamorous, but with a clear process and a few time-saving strategies, you can manage it effectively while keeping your sanity intact.
Remember:
It’s a courtesy to patients, but not your team’s ultimate responsibility.
Each office is unique—adapt the processes to fit your specific workflows.
Utilize available tools, portals, and resources to make verification as efficient as possible.
Quick Checklist: As a bonus for reading this article all the way through I have included a checklist to reference when verifying your patient’s insurance. Enjoy.
By focusing on the essentials and streamlining your approach, you’ll have more time to dedicate to what really matters—patient care and growing your practice!
Article Links:
Insurance Full Breakdown Template: Here
Quick Checklist Insurance Guide: Here
