DENTAL INSURANCE VERIFICATION CHECKLIST: BENEFITS & PRE-AUTHORIZATION

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--- PATIENT INFORMATION VERIFICATION ---
[ ] Patient First Name
[ ] Patient Last Name
[ ] Patient Date of Birth
[ ] Patient Phone Number
[ ] Patient Gender (Male, Female, Other, Prefer not to say)
[ ] Insurance Carrier

--- INSURANCE CARD DETAILS ---
[ ] Policy Number
[ ] Group Number
[ ] Subscriber's First Name
[ ] Subscriber's Last Name
[ ] Subscriber's Date of Birth (MM/DD/YYYY)
[ ] Insurance Company Name
[ ] Insurance Card Type (Primary, Secondary, Tertiary)
[ ] Insurance Card Image (Front)

--- ELIGIBILITY VERIFICATION ---
[ ] Coverage Status (Active, Inactive, Pending, Cancelled)
[ ] Plan Type (HMO, PPO, Managed Care, Fee-for-Service)
[ ] Member ID (First 4 Digits)
[ ] Effective Date of Coverage
[ ] Waiting Period Applicable? (Yes, No)
[ ] Days Remaining in Waiting Period (if applicable)

--- BENEFIT SUMMARY REVIEW ---
[ ] Annual Maximum Benefit
[ ] Deductible Amount
[ ] Coinsurance Percentage
[ ] Plan Type (e.g., PPO, HMO, Indemnity) (PPO, HMO, Indemnity, Other)
[ ] Specific Exclusions or Limitations
[ ] Waiting Period for Major Services? (Yes, No, Unknown)
[ ] Benefit Expiration Date

--- PRE-AUTHORIZATION REQUIREMENTS ---
[ ] Is Pre-authorization Required? (Yes, No, Unsure)
[ ] Procedure(s) Requiring Pre-authorization (Implant Placement, Crown & Bridge, Orthodontics, Specialized Surgery, None)
[ ] Rationale for Pre-authorization (if applicable)
[ ] Estimated Cost of Procedure (for Pre-authorization)
[ ] Date Pre-authorization Request Submitted
[ ] Details of Communication with Insurance for Pre-authorization
[ ] Upload Pre-authorization Forms/Documentation

--- COORDINATION OF BENEFITS (COB) ---
[ ] Primary Insurance Carrier (Carrier A, Carrier B, Carrier C, Other)
[ ] Secondary Insurance Carrier (if applicable) (None, Carrier A, Carrier B, Carrier C, Other)
[ ] Primary Insurance Claim Submission Order
[ ] Notes on Coordination of Benefits
[ ] COB Submission Method (Electronic Claim, Paper Claim, Clearinghouse)
[ ] Date of COB Contact

--- OUT-OF-POCKET COSTS ---
[ ] Patient Deductible
[ ] Co-pay per Visit
[ ] Co-insurance Percentage
[ ] Maximum Annual Benefit
[ ] Services with Separate Co-pays
[ ] Deductible Waived? (Yes, No)

--- DOCUMENTATION & RECORD KEEPING ---
[ ] Verification Date
[ ] Policy Number (recorded)
[ ] Notes on Verification Process (e.g., phone call details, website used)
[ ] Verification Method (Phone, Online Portal, Fax)
[ ] Authorization/Claim Number (if applicable)
[ ] Screenshot of online verification (optional)

--- COMMUNICATION WITH PATIENT ---
[ ] Patient Informed About Coverage?
[ ] Notes on Coverage Explanation (if applicable)
[ ] Estimated Patient Cost (if known)
[ ] Coverage Questions? (None, Minor, Significant)
[ ] Date of Coverage Discussion
[ ] Time of Coverage Discussion

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