> ## Documentation Index
> Fetch the complete documentation index at: https://dso.getlemma.com/llms.txt
> Use this file to discover all available pages before exploring further.

# Verify eligibility and benefits

> Run 270/271 checks at scheduling and check-in, then capture remaining maximums, frequency history, missing tooth clauses, waiting periods, downgrades, and COB.

**Dental benefits verification** combines an eligibility check with a review of plan design. The 270/271 confirms whether coverage is active, while plan details help estimate what the patient may owe. Capture both before presenting the treatment estimate.

## Prerequisites

* Real-time 270/271 enabled through your clearinghouse or PMS
* The patient's insurance card, or the member ID and payer
* A place in the chart to store the response and the breakdown

## The two-check rule

<Steps>
  <Step title="Check at scheduling">
    Start as soon as the appointment is booked. This gives staff time to resolve eligibility issues and capture the full breakdown before a treatment visit.
  </Step>

  <Step title="Check again at check-in">
    Coverage lapses, plans change at the start of the year, and employment ends. A check run three weeks ago is not evidence of coverage today.
  </Step>
</Steps>

Practices that check once, at scheduling, generate eligibility denials for exactly the population whose coverage changed in between.

## Reading the 271

Extract what the response gives you:

| Field                                      | Why                                                                                                    |
| ------------------------------------------ | ------------------------------------------------------------------------------------------------------ |
| **Coverage status on the date of service** | The threshold question                                                                                 |
| **Plan type**                              | PPO, DHMO, or indemnity. Confirm a DHMO patient's assigned provider before billing.                    |
| **Effective and termination dates**        | Confirms coverage spans the service date                                                               |
| **Deductible: total and remaining**        | Drives the estimate                                                                                    |
| **Coverage tiers**                         | Preventive, basic, and major percentages vary by plan; do not assume a "100/80/50" design.<sup>1</sup> |
| **Remaining annual maximum**               | Capture it whenever the payer reports it                                                               |
| **Network status**                         | In or out of network for this PC's TIN                                                                 |
| **Other coverage / COB**                   | Signals whether you're primary                                                                         |

**Estimate from the verification, not from the card.** Insurance cards go stale, and a card never shows how much of the maximum is left.

## The plan-design capture list

The 271 rarely contains the full dental benefit design. For treatment beyond a recall visit, use the payer portal or a documented phone verification to capture the remaining fields:

| Capture                                  | Why it decides money                                                                                                                                                                                                                           |
| ---------------------------------------- | ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- |
| **Remaining annual maximum**             | Dental plans cap the *plan's* annual payout, typically $1,000–$2,000; everything beyond it is patient responsibility<sup>1</sup>                                                                                                               |
| **Frequency limits with history**        | Common patterns include two prophylaxes a year, annual bitewings, crown replacement after 5–10 years, or one SRP per quadrant per 24 months.<sup>2</sup> Ask what the patient has already used, including at prior offices.                    |
| **Missing tooth clause**                 | Some plans exclude replacement of a tooth extracted before the coverage effective date, which can affect bridge or implant coverage.<sup>3</sup>                                                                                               |
| **Waiting periods**                      | Individual plans may impose waiting periods for basic and major services. Some carriers waive them with proof of prior coverage; confirm the rule in the certificate.<sup>3</sup>                                                              |
| **Downgrade behavior**                   | Does this plan pay posterior composites at the amalgam allowance, or crowns at a lesser-material allowance? Model it in the estimate or every posterior composite generates a surprise balance<sup>4</sup>                                     |
| **COB**                                  | With two plans, establish primacy before treatment. The subscriber's own plan is generally primary, and dependent children often follow the **birthday rule**. Check for non-duplication clauses that limit the secondary benefit.<sup>5</sup> |
| **Orthodontic and specialty carve-outs** | Orthodontic benefits often have a separate lifetime maximum and payment schedule, so verify them separately during treatment planning                                                                                                          |

Use the answers in the treatment-plan estimate and financial consent. Include expected downgrades and the remaining maximum so the patient balance is not understated. See [Bill dental claims](/guides/billing/run-the-dental-billing-cycle) for the downstream workflow.

## When to call anyway

The 271 is not complete. Call the payer or pull the portal breakdown when:

* **The visit involves treatment**, particularly care affected by the maximum, frequencies, or downgrades
* **You need history**, such as prior use of frequency-limited services, SRP dates, or extractions relevant to a missing tooth clause
* **The patient has Medicaid.** Verify through the dental benefit administrator's designated channel rather than assuming the state's medical portal contains the dental details.
* **COB is complicated**, such as two plans, a court order, or a dental-medical boundary case
* **The response is ambiguous** or the payer doesn't support real-time 270/271

## Documenting the check

**Save the 271 response and the breakdown to the chart.** Not a note saying "verified." The actual response, with its date and timestamp. When a payer later denies for eligibility, the saved 271 showing active coverage on the date of service is your strongest appeal evidence. See [File appeals](/guides/billing/file-appeals).

For a phone verification, record the date, representative's name, reference number, and information provided. Without that record, it may be difficult to support a later dispute about what the payer said.

## Batch eligibility

Run eligibility for tomorrow's entire schedule in one batch each morning and work only the exceptions. In a recall-driven practice most of tomorrow is hygiene, and batch 270s turn a per-patient task into a 20-minute daily review. Flag for manual breakdown only the treatment visits.

<Note>
  🦷 **Pediatric dentistry:** dependent children frequently have two plans through their parents, which requires a birthday-rule analysis. Capture primacy during new-patient intake instead of waiting for claim rework.
</Note>

## Steps

<Steps>
  <Step title="Enable real-time 270/271 for your payer mix">
    Confirm coverage with your clearinghouse. Not every payer supports real-time; know which don't, and know where the Medicaid dental administrator's portal is.
  </Step>

  <Step title="Build the scheduling-time check into the booking workflow">
    Make it a required step, not an optional one.
  </Step>

  <Step title="Run a batch each morning for the next day's schedule">
    Work the exceptions; have the front desk call those patients today.
  </Step>

  <Step title="Pull the full breakdown for every treatment visit">
    Put the capture list above into a structured template rather than a free-text note.
  </Step>

  <Step title="Re-check at check-in" />

  <Step title="Build the estimate from the breakdown, and collect against it">
    Remaining maximum, downgrade behavior, and deductible in; card out. Present it with the financial consent.
  </Step>

  <Step title="Save everything to the chart">
    271s, breakdowns, and call notes with reference numbers.
  </Step>
</Steps>

## Verify it worked

* [ ] Real-time 270/271 enabled for the payer mix
* [ ] Check at scheduling is a required workflow step
* [ ] Daily batch running for the next day
* [ ] Full breakdown captured for every treatment visit, in a template
* [ ] Frequency **history** asked for, not just limits
* [ ] Re-check at check-in
* [ ] Responses and breakdowns saved to the chart
* [ ] Estimates model downgrades and remaining maximums
* [ ] Phone verifications documented with name and reference number

## Common failure modes

| Failure                                    | Consequence                                        |
| ------------------------------------------ | -------------------------------------------------- |
| Checking once, at scheduling only          | Denials for coverage that lapsed                   |
| Stopping at "active"                       | Surprise balances on every major case              |
| Limits captured without history            | Frequency disallowances that verification "passed" |
| Missing tooth clause never asked           | An uncovered bridge discovered at the 835          |
| Estimating from the card                   | Overcollection, credit balances, refunds           |
| Not saving the response                    | No appeal evidence                                 |
| Medicaid verified against the wrong system | Wrong administrator, wrong answer                  |
| No exception workflow                      | The batch runs and nobody acts on it               |

## Sources

1. Delta Dental, [What is a dental insurance annual maximum?](https://www.deltadental.com/protect-my-smile/dental-insurance-101/what-is-dental-insurance-annual-maximum/); Humana, [dental annual maximums](https://www.humana.com/dental-insurance/dental-resources/what-is-a-dental-insurance-annual-maximum). Typical maximums $1,000–$2,000
2. Typical frequency schedules per Delta Dental member-company benefit guides, e.g. [Delta Dental of Washington](https://www.deltadentalwa.com/dental-insurance-101/what-is-a-dental-insurance-annual-maximum); exact frequencies live in each plan's processing policies.
3. Missing tooth clauses and waiting periods vary by certificate. Confirm them against the specific plan document.
4. ADA, [Least expensive alternative treatment (LEAT) clause](https://www.ada.org/resources/practice/dental-insurance/least-expensive-alternative-treatment-clause).
5. ADA, [Dental plans: coordination of benefits](https://www.ada.org/resources/practice/dental-insurance/ada-guidance-on-coordination-of-benefits).