Here is a checklist to use when
checking your insurance coverage. You can refer to your plan booklet, but
it is always a good idea to check with your carrier for current and up to date
information. You may want to print
this list when checking your coverage. Insurance companies determine
coverage based on specific treatment codes (long
page, please be patient) - just ask for these. Additional documentation (x-rays,
narrative, etc.) may also be required by your insurance company to fully
consider a particular claim, be sure to ask.
Click on lines
with this check
to expand or collapse the list.
today's date
person you are speaking with
client name
social security number
date of birth
subscriber name
social security number
The subscriber to an insurance
policy is the person who actually holds the policy, for example: wife is
insured through her employer, and husband is covered under her policy, wife is
the subscriber.
date of birth
employer
insurance company
mailing address
policy group number
phone number
accept electronic claims Y / N
electronic payor no.
type of insurance
regular indemnity
can see any dentist
PPO / PDO / PDP dentist chosen from a list, often reduced benefits for dentists out
of network
out of network benefits Y
/ N
HMO / DMO
must see a dentist in plan
effective date of coverage
signature on file
accept Y / N
coverage type
individual
individual and spouse
individual and children
family (including spouse and children)
overlapping coverage, how is secondary
handled
COB - Coordination Of Benefits
see more about how secondary is handled,
click
here
MOB - Maintenance Of Benefits
Carve Out
Limited Coordination
Non-Dual
Integration of Benefits
for dependents
parents not separated or divorced
birthday rule
the plan covering the parent whose
birthday falls earlier in the year pays first; the plan covering
the parent whose birthday falls later in the year pays second
gender rule
M 1st / F 2nd, or
F 1st / M 2nd
other
parents separated or divorced
parent with custody rule
the plan of the parent with custody
usually pays first
spouse of the parent with custody
(step-parent) rule
the plan of the spouse of the parent with custody (the step-parent) pays
usually pays next
parent without custody rule
the plan of the parent without custody
usually pays last
specific court arrangements
if the specific terms of a court decree state that one of the parents is responsible for the child’s health care expenses and the insurer or other entity obliged to pay or provide the benefit of that parent’s plan has actual knowledge of those terms, that plan pays first
other
dependent coverage
up to what age
age for full-time students
coverage percentages
coverage based on
UCR
fee schedule
flat amount per year up to maximum
preventive %
does it include
x-rays
basic %
does it include
root canal
periodontal treatment
periodontal surgery
oral surgery
x-rays
major %
does it include
crowns and bridges
dentures
root canal
periodontal treatment
periodontal surgery
oral surgery
annual maximum coverage
amount per person
amount per family
coverage year
calendar
subscription date (effective date of
coverage)
other
predetermination
required Y / N
over certain amount Y / N
dollar amount
waiting period
required Y / N
basic Y / N
how long
major Y / N
how long
deductible
Y / N
time period that it applies
per plan year
lifetime
type of treatment it applies to
all
per person
how much
per family
how much
preventive
waived for preventive Y
/ N
per person
how much
per family
how much
basic
per person
how much
per family
how much
major
per person
how much
per family
how much
replacement limitations
dentures (including partial dentures)
number of years
unserviceable
crowns and bridges
number of years
unserviceable
crowns for back teeth
porcelain allowed Y / N
paid for gold only
not a covered expense
missing tooth coverage
excluded Y / N
teeth missing prior to insurance policy covered or
not for
replacement
missing tooth replacement paid for
least expensive
for example, fee of partial
denture instead of bridge
web site content, design, maintenance, and funding by Steven T Bunn, DDS no commercial sponsorship or advertising
Disclaimer: The materials on my web site are not intended as a substitute for professional dental / medical advice, and accordingly you should not use this information to diagnose or treat a health problem or disease without consulting with a qualified healthcare provider. I may change or update information contained on this web site without notice to represent recent developments in health care.
It is important to understand the risks of communicating with you electronically since information will be transmitted over the public Internet, such as a third-party intercepting a message, or the message not getting through. Responses are intended to be timely; however, Dr. Steve Bunn is not liable for the lack of response or delayed responses.
Topics appropriate for email vs. a face-to-face visit include those subjects which are not time sensitive or emergency situations. If you are faced with an emergency, make an appointment with your appropriate healthcare provider or go directly to the emergency room instead of asking for advice via email.
to expand or collapse the list.
