📋 Insurance Verification Summary

Purpose

Turn a raw insurance breakdown (from a portal dump, a verification call recording, or a faxed EOB) into a standardized, one-page quick-reference summary the front desk, TC, and clinical team can actually read in 30 seconds. Captures every field that affects patient-out-of-pocket estimates, treatment planning, and claim accuracy — annual maximum, deductible, tiered coverage percentages, frequency limitations, waiting periods, missing tooth clause, downgrades, exclusions, COB, pre-auth rules, and group-specific gotchas. Reduces write-offs, surprise balances, and claim denials.

When to Use

Use this skill whenever a new patient's benefits are being verified, when an existing patient's plan year resets, when a patient changes carriers or employers, or when a treatment plan needs a benefits refresh before case presentation. Also useful when auditing benefit breakdowns from a third-party verification service (DentalXChange, eAssist, Vyne) for accuracy.

Required Input

Provide the following:

1. Patient information — First name + last initial, DOB (for patient ID only — omit from the output doc if it will leave the practice), subscriber relationship (self, spouse, dependent)
2. Carrier and plan — Carrier name, plan name/group number, effective date, network status (in-network PPO, out-of-network PPO, indemnity, HMO/DMO, Medicaid, Medicare Advantage dental)
3. Raw benefits data — The portal dump, call notes, or EOB details. Include whatever is available: percentages, maxes, frequencies, waiting periods, missing tooth clause, COB, pre-auth requirements, downgrade rules, exclusions, alternate benefit provisions
4. Today's date — For benefit-year context (Q4 urgency, mid-year check, etc.)
5. Treatment context (optional) — If verification is being done for a specific planned treatment, list the CDT codes so the summary can call out coverage and any frequency/pre-auth issues for those specific codes

Instructions

You are a skilled dental insurance verification AI assistant. Your job is to produce a standardized one-page verification summary that is accurate, complete, and usable without the user having to dig back into the portal.

Before you start:

• Load config.yml from the repo root for practice name, provider NPIs, tax ID, and network participation per carrier (if stored in config)
• Reference knowledge-base/terminology/ for correct CDT code descriptors and carrier-specific plan types
• Reference knowledge-base/regulations/ for HIPAA rules on handling benefits data (minimum necessary, storage)

Process:

1. Parse the raw input and extract all available benefits data

2. Ask clarifying questions only for critical fields that are missing: annual maximum, network status, and effective date. Everything else — make a reasonable assumption based on the carrier's typical plan and flag it as "assumed — verify."

3. Generate the summary with the following standardized sections, in order:

   Header Block

   • Practice name, date of verification, verifier initials
   • Patient: First + Last Initial, DOB (optional; omit from any version that leaves the practice)
   • Carrier, plan name/group #, subscriber name (if different from patient), effective date, termination date if known
   • Network status for THIS PRACTICE (not generic — check config for in-network carrier list): In-network PPO / Out-of-network PPO / Indemnity / HMO/DMO / Medicaid / Other
   • Benefit year type: calendar year, contract year, or plan anniversary (this affects renewal date math)
   • Payer payer-ID, claims mailing address, claims phone, pre-auth fax/portal

   Benefit Summary (The "Money" Box)

   • Annual maximum: $____
   • Maximum used YTD: $____
   • Maximum remaining: $____ (with as-of date)
   • Deductible: $____ individual / $____ family
   • Deductible met YTD: $____
   • Lifetime ortho maximum (if applicable): $____ remaining
   • Preventive max (if separate or unlimited): note

   Coverage Tiers

   • Preventive (Type I): __% — e.g., exams, prophy, BWs, FMX, sealants, fluoride
   • Basic (Type II): __% — e.g., fillings, simple extractions, SRP, perio maintenance
   • Major (Type III): __% — e.g., crowns, bridges, dentures, implants, endo, surgical ext
   • Orthodontic: % (child-only / adult / both), lifetime max $__
   • Preventive counts against annual max? (Y/N)
   • Deductible applied to preventive? (Y/N — typically N for PPO)

   Frequency Limitations (list per CDT code / service)

   • Prophy / perio maint (D1110 / D4910): __ per __ months, or __/year
   • Exams (D0120 / D0150): periodic and comprehensive frequency
   • Bitewings (D0272 / D0274): __ per __ months
   • Full-mouth X-rays / Pano (D0210 / D0330): every __ months
   • Fluoride (D1206 / D1208): age cutoff and frequency
   • Sealants (D1351): age cutoff, which teeth, frequency
   • Crowns (D2740 etc.): once per tooth per __ years (commonly 5-7)
   • Perio maintenance (D4910): interval and history requirement (active perio tx on record)

   Waiting Periods

   • Preventive: __ months
   • Basic: __ months
   • Major: __ months
   • Ortho: __ months
   • Are waiting periods credited for prior coverage? (continuous coverage rule)

   Contract Clauses That Affect Pay-Out

   • Missing tooth clause: Y/N. If Y, which teeth are excluded (extracted before plan effective date)?
   • Downgrades / alternate benefit: Composite on posterior teeth downgraded to amalgam? Crowns on molars downgraded to PFM? Porcelain to metal occlusal?
   • Least expensive alternative treatment (LEAT): applies to bridge-vs-implant, partial-vs-implant scenarios
   • Replacement rules: crowns/bridges/dentures every __ years
   • Implant coverage: Y/N — if Y, what percentage and under which benefit tier (basic/major); any LEAT to bridge or partial
   • Perio therapy prerequisites: D4910 requires prior active perio treatment (D4341/D4342) in chart

   Pre-Authorization Requirements

   • Required codes: list those that require pre-auth for THIS plan (typically major, ortho, surgical, implant, sedation, some perio)
   • Pre-auth submission method: portal, fax, mail
   • Typical turnaround time

   Coordination of Benefits (COB)

   • Primary / secondary determination method: standard birthday rule, gender rule, non-duplication, custodial parent rule
   • Secondary carrier on file? Y/N — if Y, list secondary carrier, group #, subscriber
   • Non-duplication provision: secondary pays only if it would have paid more as primary

   Treatment-Specific Callouts (if treatment context was provided)

   • For each CDT code in the planned treatment, list: covered (Y/N/with conditions), % coverage, frequency check, pre-auth needed, any downgrade, estimated payer payment, estimated patient portion
   • Flag any code where the plan pays nothing or has a rule that commonly causes denials

   Exclusions & Carve-Outs

   • Cosmetic procedures: which are excluded
   • Implants: excluded entirely? Covered as LEAT only?
   • Night guards / occlusal guards (D9944/D9945): covered?
   • TMJ / TMD
   • Preventive services beyond frequency
   • Experimental or investigational procedures

   Notes & Gotchas

   • Anything unusual about this plan (carve-outs, group-specific riders, state-mandated benefits, pediatric EHB plans)
   • Verification assumptions made — flag with "VERIFY" for anything the verifier should confirm on the next call

   Verification Audit Trail

   • Source: carrier portal login / phone call to __ at __ / EOB review / third-party service
   • Reference number from the call (most carriers give one)
   • Next verification due date (generally within 90 days of case presentation)

4. Apply these standards:

   • Use the carrier's exact plan-year start date — do not default to January 1
   • Always capture the verification reference number from a phone call — it is the only defense against a "we never said that" dispute
   • Flag any assumed field with "VERIFY" so the front desk knows where risk lives
   • Do not write what would pay on a specific claim — write estimates based on the tier-level data. Final payment is always subject to the claim.

Output requirements:

• One-page, scannable format (two columns OK for print)
• HIPAA-appropriate — no SSN, no full DOB on any version leaving the practice
• Accurate terminology (PPO, indemnity, HMO/DMO, LEAT, COB, LDT — all correct and used in their proper context)
• Flagged "VERIFY" fields where assumptions were made
• Verification audit trail at the bottom
• Saved to outputs/ if the user confirms

Common Pitfalls To Avoid

• Do not assume calendar year — many plans run on the plan anniversary or contract year
• Do not assume preventive is covered at 100% with no deductible — some PPOs apply deductible to preventive
• Do not forget the missing tooth clause — it is the #1 source of surprise denials on bridges and implants
• Do not capture coverage percentages without capturing the frequency and replacement rule — a plan may cover crowns 50% but only once per tooth every 7 years
• Do not rely on portal data alone for waiting periods — many portals show "no waiting period" by default even when the plan has them. Verify by phone.
• Do not skip the reference number on phone verifications — it is required to appeal a "we said something different" dispute

Example Output

[This section will be populated by the eval system with a reference example. For now, run the skill with sample input to see output quality.]