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The Importance of the Dental Insurance Breakdown Form [Part 2]

Ashley Bond with text, "Real-world insights from AADOM authors"

Last time we spoke about the three reasons why a dental insurance breakdown form is crucial for a dental office. The patient experience, collecting 100%, and for your own growth and credibility. If you missed that article, I suggest you go back to read it before moving along to part two.

Now it’s time to start digging into each question on the breakdown form, what it means, and why it’s there.

Insurance and patient details (names, IDs, 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 submit them electronically.

This delays payment to your office and ultimately adds more work for whoever is calling about 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 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 reset 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 require the patient to wait 6 or 12 months before they cover crowns and basic fillings?

That’s what a waiting period is.

The patient must wait this long until their benefits cover a particular 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 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, or partial procedures.

If there’s 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 the patient was already under this insurance policy. Otherwise, they will not be covered at all.

Annual maximum and remaining

How many 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 doesn’t mean you don’t perform the necessary treatment, but it does mean you need to give the patient an accurate treatment plan.


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 the deductible info and ask if it’s 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 the 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 the process and give your patient the best insurance estimate possible.

Meet the Author

Ashley Bond in black blazer and pearl necklaceAshley Bond is the founder of Bond Dental Consulting… This text opens a new tab to the official website…, a company specializing in remote dental billing, A/R, and dental consulting.

Her passion is to help practices stress less, collect more, and get back to what’s really important: the patient relationship.

Ashley has over a decade of experience in the dental field, beginner her career at her father’s dental practice. There, she learned the ins and outs of everything the business entails. She has played many roles, including treatment coordinator, office manager, marketing manager, and insurance guru.

Get all the latest dental tips and tricks on her weekly podcast, “Quick Bites for your Dental Office… This text opens a new tab to the podcast’s web page…,” and follow her on Instagram (@bonddentalconsulting)… This text opens a new tab to her company’s Instagram… and Facebook… This text opens a new tab to her company’s Facebook….


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