Remote Dental Billing and Patient A/R

Let’s Breakdown The Insurance Breakdown Form: Part 2

Last time we spoke about the main three reasons an insurance breakdown form is crucial for a dental office. To recap the three reasons a breakdown is so important are for patient experience, collecting 100%, and for your own growth and credibility. If you missed that article, I suggest you read that first before you move along here.

Now let’s start digging into each question on the breakdown form and what it means and why it’s there. If you would like to follow along follow this link to get my free detailed insurance breakdown form: www.bonddentalconsulting.com/dental-freebies


  • Insurance and patient details (names, ID’s, group names, group numbers, payor ID, addresses, etc): This first piece of information is vital because if any of this information is incorrect, you risk your claims being rejected when you send them electronically. This delays your office getting paid and ultimately adds more work for whoever is calling on outstanding insurance claims.


  • Fee schedule or UCR- This question is very important if you are a fee for service provider (i.e. you are not in network with a lot of dental insurance companies). You want to know here if this insurance company is based off the UCR, which is the usual, customary and reasonable amount, or if they base their fees off their own fee schedule or table of allowances. A fee schedule is typically very low coverage.


  • Calendar or Benefit Year- Does this plan renew every January 1 or does it renew during a random month in the middle of the year? If a plan is a benefit year and renews in October, you do not want to give the patient a treatment plan once they have reached their maximum because your software says they renew in January.


  • Waiting Period: Does this plan make the patient wait 6 or 12 months before they cover crowns and even fillings? That is what a waiting period is. The patient must wait this long until they cover this procedure. This is vital information to know, especially if this is a new plan for the patient. The last thing you want to tell a patient is that their insurance is estimating to cover half of their crown bill, when in reality they owe the full amount! That can be a $500-$600 mistake.


  • Missing Tooth Clause: This question is especially important if your office performs a lot of implant/bridge/partial procedures. If there is a missing tooth clause then that means that this insurance company will only cover restorative procedures for missing teeth if the extraction was performed while they had this insurance. Otherwise, they will not be covered at all.


  • Annual Maximum and Remaining– how much insurance dollars does this company allow per calendar or benefit year? Also, has this patient used any benefits from another office during this year? Again, if a patient had their wisdom teeth extracted from an oral surgeon and then needs a crown performed, you need to know that there are no remaining benefits to use before the end of the year. It does not mean you don’t perform the necessary treatment, but it does mean you need to give the patient an accurate treatment plan.


  • Deductibles- how much does this insurance charge before they cover services? Typically a company will take away $50-$100 before they cover basic and major work. You need to double check this and ask if it is waived on preventative. If a patient comes in for a cleaning and they have a $50 deductible that is NOT waived on preventative, then you need to make sure to collect that at time of service and not surprise the patient later.


As I always say a patient does not mind paying their dental bills but what they do mind is paying surprise dental bills. Take the surprise out of it and give them the best insurance estimate you can. If you are ready to outsource your dental insurance headaches to the professionals, we would love to be in touch. Reach out to me by email at ashley@bonddentalconsulting.com or see how we can help you at www.bonddentalconsulting.com/dental-billing.

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