Insurance

Insurance calculator

Patient & treatment

Insurance verification

Treatment

Months

Addons $

Discount

Manual discount $

Overrides

Fee override $

In/Out override

Ortho max override $

Insurance override

Pick a verification (or set overrides) and a treatment to see the estimate.

New verification

Patient Insurance Verification

Agent Name: Ref #:

Patient Full Name: DOB:

Chart #: Age:

Relationship:

Insured Party Information

Subscriber Name: Subscriber DOB:

ID#/SSN: Employer/Group:

Group #:

Insurance Company Information

Insurance Company: of

Insurance Phone #:

Mailing Address:

Fax #: Contact note:

Orthodontic Benefits

Effective Date: In/Out of Net:

Maximum (IN): Payable at % (IN):

Maximum (OUT): Payable at % (OUT):

Benefits used to date:

Benefit Lifetime/Yearly?: Yearly Renew Date:

Deductable ($): Deductable renews:

Preauth Required?:

Cover Work in Progress? Med Necessary?:

Dep Age Limit: Age if FTS:

Adult Coverage:

Waiting Period? How long? (months):

Payment

Assignment of Benefits:

Initial Banding %: Initial Banding $:

Payments Made: Payment Frequency:

Dual Insurance

Do you Coordinate? How?:

How do you pay out benefits when coordinated?

Completed by:

Verifications

Contracted rates

Treatment fees

Discounts

Percent discounts apply to the contracted rate in-network, the full fee out

Users

Admins manage reference tables and delete records; staff work verifications. Cognito sign-ins match by email; new SSO users arrive as staff.

Audit log

Every change to verification records — who, when, and what. Click a row for the field-by-field diff.