The 12-Field Verification Checklist — Module 4

Every verification follows the same framework. These are the 12 data points you must confirm before a patient sits in the chair.

Sample Insurance Card — Annotated with 12 Verification Fields

Delta Dentalof Texas

DPPO

Subscriber

Maria Gonzalez

Member ID

DDX-88421057

Group #

GRP-7744210

Effective Date

01/01/2026

Network

Delta Dental DPPO

Dependents

Luis (spouse), Sofia (child, 8)

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Coverage Summary

Deductible (Ind/Fam)$50 / $150$75 / $225

Annual Maximum$1,500$1,000

Preventive100%80%

Basic80%60%

Major50%40%

Waiting periods: Basic 6 mo, Major 12 mo from effective date.

Frequency: Prophylaxis 2x/year; BWX 1x/year; Pano 1x/3 years.

Age limits: Sealants to age 14; Ortho to age 19.

Missing tooth clause: Applies — teeth lost prior to effective date not covered.

Pre-auth required: Crowns, bridges, implants, ortho.

COB: This plan is primary. Birthday rule applies for dependents.

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#	Field	What to Confirm
1	Eligibility	Is coverage active? What's the effective date?
2	Plan Type	DHMO, DPPO, Indemnity, or Discount plan?
3	Network Status	Is the provider in-network or out-of-network?
4	Deductible	Annual deductible amount. How much has been met?
5	Annual Maximum	Total benefit per year. How much remains?
6	Benefit %	Preventive (typically 100%), Basic (80%), Major (50%)
7	Waiting Periods	Days/months before certain services are covered
8	Frequency Limits	How often can procedures be done? (e.g., cleanings 2x/year)
9	Age Limits	Sealants under 14, ortho under 19, etc.
10	Missing Tooth Clause	Does the plan exclude teeth lost before coverage?
11	Pre-Authorization	Which procedures require prior approval?
12	COB	Primary vs. secondary insurance. Birthday rule.

Pro tip: Print this checklist and keep it next to your workstation until it becomes second nature. Most experienced specialists can verify all 12 fields in 8–12 minutes.