Navigating the New Year: The Importance of Dental Insurance Verification for Practices

by | Published on Oct 6, 2023 | Dental Insurance Verification

Importance of Dental Insurance Verification
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Many health insurance and dental insurance plans operate on a calendar year basis, running from January 1st to December 31st. The start of the year often marks a reset for health insurance benefit plans. This annual reset can bring about adjustments to coverage, premium, benefits, provider networks, and more.

As New year dawns, it is essential for policyholders to review any updated plan documents to understand these changes. It’s crucial for dental practices to be aware of any modifications to their patients’ current plans. Understanding and adapting to these shifts is essential, considering the potential impact on patient coverage, premiums, and other policy details. That’s why dental insurance verification services are crucial as benefit plans reset at the beginning of the year.

Insurance verification stands out as the cornerstone of a seamless dental billing process, paving the way for payable claims. It ensures claims can be processed seamlessly, avoiding wasted time and resources on errors or unnecessary claims. Also, without proper verification, accurately communicating treatment costs to patients becomes challenging.

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The Annual Benefits Reset – Why Verifying Insurance Eligibility is Crucial

Insurance plans typically offer open enrollment periods, usually occurring towards the close of the year. The 2024 Open Enrollment Period (OEP) begins November 1, 2023, and ends January 15, 2024, in most states. This presents individuals with the opportunity to review and modify their coverage for the upcoming year. During this period, they can reassess and make changes to their existing plan, enroll in a new plan that aligns more closely with their individual needs, or explore additional coverage options. Dental insurance eligibility verification is necessary for practices to navigate the changes to patient benefits.

At the beginning of each calendar year, insurance plans may reset the following benefits and coverage limits:

  • Deductibles: Deductibles are amounts that policyholders must pay out of pocket before their insurance coverage kicks in. As the New year begins, deductibles frequently reset to zero, requiring individuals to fulfill the deductible again before certain services are eligible for insurance coverage. Many dental plan providers typically adhere to the calendar year, spanning from January to December.
  • Annual maximum: Many dental plans have an “annual maximum” or “annual benefit maximum,” representing the total sum that the dental insurance provider will contribute towards a member’s dental care over a 12-month period. This timeframe is referred to as the benefit period, often aligning with the calendar year for numerous plans. The annual maximum on dental plans resets at the commencement of each benefit period.
  • Benefits and coverage: The Affordable Care Act (ACA) mandated that private health insurers fully cover preventive care services at no cost to patients. Certain benefits, such as preventive services, screenings, or wellness programs, may reset at the beginning of the year. This means that individuals may have access to these benefits again, and any limits or quotas on services may renew.

So, with plan benefits resetting at the beginning of the year, accurate dental insurance verification is crucial for precise billing. Dental practices need to fully verify all patients with a complete breakdown. This ensures that dental practices bill patients correctly based on their updated coverage, avoiding disputes and enhancing financial transparency.

What is a Comprehensive Dental Insurance Breakdown?

Verifying patient coverage requires designing a comprehensive checklist to obtain benefits information. Here is a complete insurance verification checklist for effective dental billing and patient communication:

Patient Information:

  • Verify and record accurate patient details.
  • Confirm the patient’s insurance coverage effective date.

Insurance Provider Details:

  • Gather information on the dental insurance provider.
  • Confirm the policy number and group ID.

Coverage Details:

  • Determine coverage type (e.g., PPO, HMO).
  • Verify coverage for routine check-ups, preventive care, and major procedures.


  • Identify the deductible amount.
  • Determine if the deductible has been met for the current benefit year.

Co-payments and Coinsurance:

  • Determine the amount the patient is responsible for (co-payment).
  • Verify the coinsurance percentage, if applicable.

Coverage Limits:

  • Check for any annual or lifetime maximums on coverage.
  • Verify specific limitations on certain procedures.

In-Network Providers:

  • Verify if the dental office is in-network with the insurance provider.
  • Clarify any differences in coverage for in-network vs. out-of-network providers.

Claim Submission Procedures:

  • Confirm the preferred method for submitting claims (electronic, paper).
  • Obtain necessary forms or information required for claim submission.

Coordination of Benefits (COB):

  • If the patient has dual coverage, determine the primary and secondary insurance.
  • Understand the coordination of benefits process.

Waiting Periods:

  • Check for any waiting periods for specific procedures or coverage.
  • Communicate waiting period details to the patient.

Renewal Dates:

  • Note the renewal date of the insurance policy.
  • Communicate any potential changes in coverage for the upcoming benefit year.

After obtaining all necessary information, the dental office should inform the patient about their coverage. When communicating changes in coverage at the beginning of the year to patients, it’s important to explaining any financial responsibilities and address their queries. This helps patients make informed decisions about their dental care. Practices should also maintain accurate records of insurance verification for billing purposes and future reference.

As the healthcare landscape evolves at the beginning of each year, dental practices must proactively engage in comprehensive insurance verification processes. However, verifying insurance can be complex and time-intensive. It demands careful attention to detail since mistakes may lead to denied claims, delays, or unforeseen expenses for the patient. That’s why outsourcing the task a practical option.

A dental insurance verification company can help practices design a checklist based on their practice’s specific needs and insurance plans. They will call the insurance company to verify patient coverage, confirm that the policy is active and that the patient is eligible for the claimed benefits. This not only ensures accurate billing but also fosters transparent communication with patients, minimizes financial surprises, and prevents claim denials. Experts can help dental offices can navigate the complexities of changing insurance policies and provide quality care while maintaining financial stability.

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Natalie Tornese

Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.

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