Insurance Verifications vs Insurance Breakdowns

Insurance verifications and insurance breakdowns serve two different functions within a dental office.

Insurance verification

An insurance verification is the process of confirming a patient's basic insurance information and whether they have active dental insurance coverage. 270/271 eligibility checks are a good mechanism to verify a patient has an active insurance, and to validate the information you have is correct. As we've seen in other sections, payer systems can be quite picky about what it accepts, and the same systems will be used to process claims, so validation of patient information is an important function within a dental office. It's a bonus when a payer gives addtional details about the plan, like limitations and patient history. This works great for recurring patients, especially if you've already updated a plan within the calendar year. Tuuthfairy is partners with three of the largest dental clearinghouses: ChangeHealth, DentalXChange, and Availity to provide verification support, along with an inference layer on top of EDI to normalize data into easy to use primitive data primatives.

Does a patient have any more cleanings covered this year?

With 270/271 alone, you cannot answer this question. Most dental plans offer 2 cleanings per year. With 270/271 data, history is not always available, and when it is, only the last visit date is defined in the spec. Determining if a patient is still eligible for a cleaning, is not possibly by 270/271 alone. Payer portals give extensive history, and would allow an office to see if a patient has had 2 cleanings in a calendar year, and to make a determination if they're eligible on a given date.

Insurance breakdown

For new patients, or new plans, a more comprehensive process is required. An insurance breakdown is the process of gathering and documenting all of the details of a patient's dental insurance plan. It aims to provide a complete picture of the patient's benefits and financial responsibilities and to determine eligibility at the procedure level. Many providers will call/fax payers for these details, or on payer portals, a web interface that provides more exhaustive lookup methods, and higher fidelilty data.

With tuuthfairy...

With tuuthfairy, you don't have to make the destinction. By connecting your payer portals, tuuthfairy will connect to the appropriate clearinghouse or payer portal, and normalize the data in a consistent format. Once complete, you can query the data that you need, and use for insurance verifications, full insurance breakdowns, appointment scheduling, benefits determination, or payments.

{
  benefits: [{
    category: 'preventive',
    code: 'D1110',
    coInsurance: 1.0,
    limit: 1,
    period: 2,
    periodUnit: 'year'
  }],
  serviceDates: [{
    code: 'D1110',
    date: '01/10/2023'
  },
  {
    code: 'D1110',
    date: '07/20/2023'
  }]
}