Reading the eligibility breakdown

When Amy verifies a plan, she writes back the same benefit detail your team would read off a payer portal — just faster, and organized into cards you can scan in a few seconds. This article walks through each card on the coverage snapshot so you know exactly what you're looking at before a patient sits down.

To find any patient's breakdown, see Where do I see what insurance Amy verified?.

Plan summary: the four numbers that matter most

The Plan summary card sits at the top because it answers the questions a front desk gets asked all day.

• Annual max — the dollar figure the plan will pay this benefit year, shown as what's remaining. When a patient is close to their cap, this is the number that tells you a treatment plan may spill into next year.
• Deductible — what the patient owes before the plan starts paying. You see the individual deductible (met vs. total) and the family deductible on the same card. When it reads Met, there's nothing left to collect on that front.
• Out-of-pocket max — the most the patient will pay this year before the plan covers the rest. Some plans don't report one, in which case it shows n/a.
• Network — whether this plan treats your practice as In-network or Out-of-network. This drives what the patient actually owes, so check it before quoting anything.

Coverage by category

The Coverage by category card shows the plan's coverage percentages grouped the way dental benefits are written:

• Preventive — cleanings, exams, and x-rays (often 100%).
• Basic — fillings, simple extractions, and similar work.
• Major — crowns, bridges, dentures, and other high-cost procedures.

These percentages, combined with the deductible and annual max above, are everything Amy needs to produce a one-click cost estimate for a visit — which you can then send straight to the patient (see the estimate section below).

Special clauses & limitations

This is the card that saves practices from surprise write-offs. When the payer returns them, Amy surfaces the fine print:

• Frequency limits — how often a benefit is allowed, such as two cleanings or one set of bitewing x-rays per year. Frequencies tied to a specific procedure code show up next to that procedure.
• Waiting periods — a window a new member must wait before major work is covered.
• Pre-authorization — procedures the payer wants approved in advance.
• Missing tooth clause and coordination of benefits (COB) — special rules that change how a claim is paid.

Plan basics

Plan basics holds the identifying details the verification was run against: member ID, subscriber name, subscriber date of birth, relationship (self, spouse, child), group number, payer ID, plan type, and the plan's effective and termination dates. If a check ever fails, this is the card you'll open to fix a typo — see A verification failed — what do I do?.

Turn the breakdown into a patient estimate

Because the breakdown carries coverage percentages, the deductible, and the annual max, you can build a cost estimate without doing the math by hand. Add the procedures you're planning, and Valian applies the plan's coverage — including a note when the annual max applies — then lets you send the bill estimate to the patient by text or email. The estimate is saved to the patient's conversation so there's a clean record of what you quoted.

Reading dates and freshness

Two dates matter on any breakdown:

1. The verification date — when Amy last confirmed this with the payer. The status pill in the header shows it as "Verified 3 hours ago" and turns amber to Verification expired once it's old enough to re-check.
2. Effective and termination dates — the payer's own window for the plan. If the effective date is in the future or the termination date has passed, coverage may read as inactive even though the details look complete.

When a breakdown is stale or you've changed a field, run a fresh check — see Re-running an insurance check.

Frequently asked questions

Why is a coverage percentage blank? The payer didn't return it electronically for that category. Amy never invents a number — a blank means "unknown," so confirm with the payer if it's load-bearing.

The deductible says "Met" but the patient disagrees. "Met" reflects claims the payer has already processed. If a recent claim hasn't posted, the figure can lag reality. Re-verify closer to the visit for the latest.

Does out-of-network mean the patient isn't covered? No. It means the plan pays at its out-of-network rate, which usually leaves the patient owing more. The Plan summary and Coverage by category still apply — just at the out-of-network level.