1 · Patient and subscriber
Patient name
Patient date of birth
Appointment date
Subscriber name
Subscriber date of birth
Relationship to patient
Member / subscriber ID
Subscriber employer
2 · Plan and network
Insurance company
Group number
Plan type (PPO, DHMO, indemnity, Medicaid)
Effective date
Termination date, if any
Office network statusIn networkOut of network
Fee schedule / network name the plan uses for this office
3 · Maximums and deductibles
Benefit yearCalendarPlan year from ____
Annual maximum $
Used to date $
Remaining $
Deductible, individual $
Met to date $
Applies toPrevBasicMajor
Lifetime ortho max $ / used $
4 · Coverage by category
| Category | Plan pays % | Waiting period | Notes (e.g. posterior composites, buildups) |
|---|
| Diagnostic and preventive | | | |
| Basic (fillings, simple extractions) | | | |
| Periodontics (SRP, perio maintenance) | | | |
| Endodontics | | | |
| Oral surgery | | | |
| Major (crowns, bridges, dentures) | | | |
| Implants | | | |
| Orthodontics (age limit: ____) | | | |
5 · Frequencies and history
| Service | Frequency allowed | Counted per (calendar, benefit year, rolling 12 months) | Last date paid |
|---|
| Periodic exam (D0120) | | | |
| Adult / child cleaning (D1110 / D1120) | | | |
| Perio maintenance (D4910); shares a limit with cleanings? | | | |
| Bitewings | | | |
| Full-mouth series or panoramic | | | |
| Fluoride (age limit: ____) | | | |
| Sealants (age and teeth covered: ____) | | | |
| Crown / bridge replacement | | | |
6 · Clauses and limits
Missing tooth clauseYesNo · Teeth affected
Alternate benefit (downgrade) on posterior compositesYesNo
Predetermination required for
Other insurance on file (coordination of benefits)YesNo
7 · Claims and call record
Payer ID (electronic claims)
Claims mailing address
Claim filing limit (days)
Verified byPortalPhone271
Representative name
Call reference number
Date and time
Notes