• Sarah Beth Herman

Breakdown of Benefits

Updated: Aug 11

Proper Care + Generating Revenue: A guide to the best breakdown of benefits you've ever seen.


We think it is time our breakdown of benefit's leveled up!


Let's talk about what your dental offices breakdown of benefits... we're talking the "should and should not's" of this hot topic.


First, prepare your practice to verify benefits with the mindset that this is for the best patient care possible and to generate revenue. Your dental practice is a "for-profit" company. Yes, you are in the medical/dental field so you have a duty to provide care for patients according to the oath taken at dental licensing. But does that oath mean you do not work to know how you can maximize benefits and patient care, simultaneously? No. The answer is emphatically, no.


Second, every time you hire someone for dental front office, dental admin or dental office manager, you are going to receive a new opinion or theory on how things should be run in the dental office. This is tough because how do you know what is the right thing to do? Welp, look no further, come back to this blog post for all the updates you ever need, and yes, they are free.


Ok, let's get to business here. I think it's best to bullet point this mama of information so we can keep track. Let's start with my favorites...


Did you know...


  1. In the average dental practice, there are over 3 million dollars in pano's and pa's that go overlooked throughout the lifetime of the dental office? $3,000,000.00 Let that sink in for a minute.

  2. The 4210 + 4211 codes can be billed for crown lengthening when used with a laser?

  3. There are some insurances who have a specific number of days you must wait to perform a 4910? Some require only 6 weeks and therefore this can be done sooner than 3 months after the 4341/4342.

  4. Some insurance companies allow coverage for a temp crown (2799) and it is not inclusive of a crown code?

  5. Irrigation can be a covered benefit but if you do not ask "is it inclusive with SRP?" it can still be denied?

  6. 4346 (scaling) + 4355 (FMD) can have age limitations?

  7. Implants can downgrade to partials?

  8. Bone graft can be covered but if placed with an implant it can be denied if there is no implant coverage?

I mention these top 8 questions because it is what I see first with breakdowns when we onboard new clients.



Breaking down the Breakdown

(yes, we really use this form for our clients and its fully customizable for your dental office.)


Let's talk initial information.

  1. Not every insurance offers all of the information your office may want to gather. Be patient and understand that some insurance companies have spent a lot of time creating plan policy while others have more straight forward payment processes.

  2. Get the Representatives name + Reference number if you call for a break down. (say it louder for the people in the back)

  3. We have had more than one occasion where a rep states coverage and the claim is later denied. We record all calls and document every reference number and rep name. So, when the claim is denied, we appeal it with the reference number and recording and BOOM - you've got yourself a PAID CLAIM! (We always call and escalate this ahead of time)

  4. Pre-Auth's... Check this. You do not want to be caught with a plan where pre-auth's are required and you never sent one in.

Coverage details are important, especially if your office offers Orthodontic treatment. If you need help with ortho billing, check out our blog on this topic. It is seriously a life-saver.


  1. Know the difference in ortho max vs plan max (two different things).

  2. Check your waiting periods

  3. Check for missing tooth clause. (A missing tooth clause protects the insurance company from paying for the replacement of a tooth that was missing before the policy was in effect. But it also hinders the patient if they were unable to get insurance until that point and need to have treatment done to improve their dental health).


Diagnostic and Preventive is a category often over looked. Let's take a look at the value of checking the information we have pictured here.

  1. CBCT, check it. Of course if you do not offer this, thats ok. But imagine how many night guards you can get here??? Many patients are silent sufferers.

  2. Find out if BWX are downgraded to FMX, if you do not you could end up writing off services rendered.

  3. Are exams shared? If they are not, you could have frequencies available to use for different exams. If they are, you could be performing an exam that is not covered. Do not just assume its going to be covered because it is a different code.

  4. Fluoride, Sealants and Preventive Resin Restorations all should have Age checks, Pre-Molar Checks and HISTORY! Say it again, folks... HISTORY!!!



Restorative eligibility verifications can bring great information to your dental practice, as long as attention to detail is made.

  1. Check for downgrades + what the alternate benefit code is. A standard practice for most dental practices is to assume a downgrade is to a PFM but it could downgrade to a base metal. Know insurance plan provisions and policy.

  2. Do you know when to bill out the crown? Some insurance plans will not pay unless the crown is seated and they require a PA of the area to prove it!!

  3. Are you checkin inlays/onlays etc? All of which are a great alternative to fillings due to the structure. (I know you know this.)

  4. Last but not least, my fav.... Are crowns covered for Bruxism? This is relatively new (last 1-2 years) but it is becoming increasingly common for this type of coverage).


The thing about Implants, Oral Surgery and Adjunctive is that most front office or administrative team members have little knowledge on how this works. So, if thats you, it is ok! Just start slow and learn your terminology. Learn how plans interact with various types of procedures.

  1. Some insurance policy's actually pay implants regardless of coverage in certain scenarios.

  2. In recent months we have begun to see separate maximums specifically for implant coverage that does not apply to the standard maximum (similar to Ortho).

  3. Check to see if Implant coverage exists but the code is downgraded to a partial and paid at the partial fees/benefit level.

  4. Bone grafts/implants: Insurances can be super tricky and deny coverage if placed the same day or in conjunction with an implant.

Of course, we have breakdowns of benefit which are much more detailed than this. Every break down we create for our clients is specific to their office needs. The information you are reading here is likely less than 5% of everything you need to know about verifying insurances for your patients. The key is to understand how your dentist diagnoses and treats patients so you are able to understand how their plan will work in your office. Every dentist is different and their level of urgency, conservativeness and experience will all vary. Each of those three things play large roles in delivering treatment plans.


We often update this page frequently with tips and tricks for break downs. This information is free for everyone and not intended to replace or undermine the diagnosis of any dentist or dental professional.


Interested in learning more about how we can support your practice? Take a look around our website and schedule a call to chat, we would love to learn more and help your practice to thrive!!


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Disclaimer:

These materials are intended to provide helpful information to dentists and dental team members. They are in no way a substitute for actual professional advice based upon your unique facts and circumstances.This content is not intended or offered, nor should it be taken, as legal or other professional advice.You should always consult with your own professional advisors (e.g. attorney, accountant, insurance carrier). To the extent Dentistry Support has included links to any third party web site(s), Dentistry Support intends no endorsement of their content and implies no affiliation with the organizations that provide their content. Further, Dentistry Support makes no representations or warranties about the information provided on those sites.

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