Proper insurance verification prevents surprises.
When you verify correctly, the patient knows their exact responsibility before treatment. No surprise bills. No denied claims. No confusion.
The Step-by-Step Process
Step 1: Get the insurance card from the patient.
Document member ID, group number, plan type (PPO, HMO, Medicaid, Medicare, TRICARE). Ask: “Is this your primary insurance? Do you have secondary?”
Step 2: Call the insurance company (number on the back of the card).
Select benefits verification option. Provide member ID and date of birth.
Step 3: Verify patient eligibility.
Is the patient still covered? Is coverage effective? Are there any gaps?
Step 4: Ask for the coverage breakdown.
Preventive (cleaning, exams): Usually 100% covered.
Basic (fillings, extractions): Usually 80% covered.
Major (crowns, bridges, implants): Usually 50% covered.
Ortho (braces): Usually 50% covered (sometimes not covered).
Cosmetic: Usually 0% covered.
Step 5: Ask about deductibles and annual maximums.
Has the deductible been met this year? What is the annual maximum benefit (usually $1,000-1,500)?
Step 6: Ask about specific procedures.
If the patient needs a crown: “Is crown coverage at the major benefit level?” If they need implant: “Are implants covered or considered cosmetic?”
Step 7: Ask about prior authorization.
Some treatments require pre-approval. “Does this plan require prior authorization for crowns?” “For implants?”
Step 8: Document everything.
Write down all information. Put it in the patient’s chart and your PMS. Do not rely on memory.
Step 9: Send patient a summary.
Email or text the patient their coverage details. “Your plan covers preventive at 100%, basic at 80%, major at 50%. Your deductible is $50 and has not been met. Your annual maximum is $1,200.”
Common Verification Mistakes
Not asking about deductibles: Patient thinks they have no responsibility. You submit claim. Deductible is still owed. Patient gets surprise bill.
Not verifying annual maximum: Patient gets treatment in December. Annual maximum is reached. If they need more treatment, they pay out-of-pocket. They blame you for not warning them.
Not asking about specific procedure coverage: You assume crown is covered at major benefit level. It is actually considered cosmetic and not covered.
Not documenting: You verify over the phone. No one writes it down. Two days later, the verification is forgotten. Claims are submitted wrong.
Not asking about prior authorization: Certain treatments require pre-approval. You submit claim without pre-auth. Claim is denied. You have to resubmit.
Reach Academy Training
Reach Academy covers the entire verification process. Your remote team member learns:
- What questions to ask
- How to navigate insurance phone systems
- How to escalate if you get the wrong department
- How to document in your PMS
- How to communicate findings to the patient
AI-Amplified Verification
HIPAA-grade AI tools show:
- Your PMS verification checklist (what to ask)
- Automated documentation (information populates directly into patient chart)
- AI notes patterns (“This plan always denies cosmetic. Do not bill it.”)
- Patient communication templates (“Here is what your patient’s coverage is”)
FAQ
**Q: How long does verification take?**
A: 10-15 minutes per call. Some insurance companies are faster, some slower.
**Q: What if the patient is in-network with multiple plans?**
A: Always verify coordination of benefits (COB). One plan is primary, one is secondary. You need to know which is which.
**Q: What if the insurance company will not tell me coverage?**
A: Some plans require patient to authorize information release. Ask the patient to call their HR/benefits department and request they send you the coverage information.
**Q: Should I verify before every appointment?**
A: For existing patients, once per year. For new patients, always. For existing patients with new treatment, always.
**Q: How do I avoid insurance claim denials?**
A: Accurate verification. Clean claims. Proper pre-authorization. That covers 90% of denials.