Reading the eligibility breakdown

When you run a check, the carrier sends back the same benefit detail your team would read off a payer portal, just faster. Valian lays it out so you can scan it in a few seconds. This article walks through each part so you know exactly what you're looking at before a patient sits down.

You see the answer in two places on the Verification tab:

• Click the patient's row for the quick view: four tiles (Coverage, Deductible, Annual max, and the Preventive · Basic · Major percentages), then Plan basics, Coverage by category and Build procedures.
• View the full benefits report, at the bottom of the open row, opens the patient's own page with every card described below.

Plan summary: the four numbers that matter most

The Plan summary card sits at the top of the full report because it answers the questions your office gets asked all day.

• Annual max: what the plan will still pay this benefit year, shown as what's left, with the plan total and what has been used under it. 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 still owes before the plan starts paying. You see the individual deductible (met vs. total), and the family deductible under it when the carrier sends one. 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 the carrier says this plan is In-network or Out-of-network. This drives what the patient actually owes, so check it before quoting anything. Which side of the plan the numbers show comes from your carrier list in Settings › Insurance, see Syncing your carrier list.

When the carrier doesn't send a number, the card says Not reported. A missing number is never shown as $0.

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.
• Ortho: braces and other orthodontic work, with the lifetime maximum when the carrier sends one.

Every category starts closed. Click one to open it and see your own codes from Settings › Services under it, with what the plan pays for each. Your codes show on every result, even one that was checked before you added the code. The check itself asks the carrier for the plan's dental benefits; your codes are never sent to the carrier. Until you add your services, a sample set of common codes shows instead.

Special clauses & limitations

This is the card that saves practices from surprise write-offs. It sits on the full report, under Coverage by category, and lists the fine print the carrier returned:

• 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 also show next to that code in Coverage by category.
• Waiting periods: a window a new member must wait before major work is covered.
• Pre-authorization: procedures the carrier 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 details the check was run against. On the full report that's the carrier, the plan and plan type, member ID, group number, the policy holder and their relationship to the patient (self, spouse, child), the holder's SSN (last four only), the holder's address, and the plan's effective date. The open row shows a shorter version with the plan year and your network status. If a check ever fails, press Edit on this card 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 codes you're planning in Procedures on the full report (or Build procedures in the open row). Valian prices each code with your fee from Settings › Services, applies the plan's coverage, and shows Fees, Insurance pays and Patient pays, with a note when the annual max applies to this visit. A code with no price yet is listed but not counted until you add your price. The plan you build is saved on the patient, so it's still there next time. Nothing is sent to the patient from here.

Reading dates and freshness

Two dates matter on any breakdown:

1. The check date: when the carrier last answered for this plan. The header of the full report shows it as "Verified 3h ago". After 30 days the patient is marked Expired on the full report and Re-check on the Verification list, so run it again before the visit.
2. The plan's own dates: the effective date and the plan year. If the plan hasn't started yet or has already ended, coverage reads Inactive even though the other details look complete.

Every check you run is kept in Verification history at the bottom of the full report. Open report on an older run shows the benefits exactly as the carrier answered that day.

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 does a coverage percentage say "Not reported"? The carrier didn't return it electronically for that category. Valian never fills in a number. Codes in that category are left out of the estimate, so confirm with the carrier if the number matters.

The deductible says "Met" but the patient disagrees. "Met" reflects claims the carrier 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.