Improving the Dental Eligibility and Benefit Verification Process


The dental industry has been slower than the medical industry to adopt EDI practices for eligibility and benefit verification. Change Healthcare’s Dental Benefits Advisor will enable dental providers to leverage the benefits of technology to improve processes.

By: Nick Dietmen, Senior Director of Dental Network Services at Change Healthcare

Eligibility and benefit verification are critical processes in the dental field. Providers must quickly gather this data from payers to give correct coverage information to patients and charge the right amount at the time of service.

Unfortunately, providers have struggled tremendously to quickly get this data from payers over the past 20 years.

Dental industry lagging in EDI

Electronic Data Interchange (EDI) speeds processes like eligibility and benefit verification. However, the dental industry lags in adopting this technology.

According to a recent study by Change Healthcare and the American Dental Association, 84% of medical providers used fully electronic processes in 2021 versus 64% of dental providers. Some dental providers continue to rely on a hybrid of e-transactions and manual procedures.

Subpar transaction sets

Existing EDI processes were based on the 270-271 Transaction Set Responses developed for the medical industry.

However, dental benefits may differ from medical benefits. With medical benefits, coverage is usually calculated as a percentage and deductibles are a factor. Dental benefits may involve different payment types for different service categories, though most are also based on percentages and PPO plans usually have a deductible. That’s why EDI transaction sets did not meet the needs of the dental industry. White Paper Nick Dietmen Senior Director of Dental Network Services Change Healthcare Nick Dietmen is the senior director of dental network services at Change Healthcare, where he focuses on helping dental providers and payers save time and money by being more efficient in their eligibility and benefits verification, billing, and credentialing operations. Improving Dental Eligibility and Benefit Verification 64% of dental providers used fully electronic processes compared with 84% of medical providers.

Providers couldn’t get key info

Most importantly, providers weren’t receiving the information they needed from payers via the 270-271 Transaction Set Responses.

Providers would receive 271 Transaction Set Responses with too much or too little data or data in the wrong format. Plus, the information was often subject to interpretation.

To fill in the information gaps, providers would spend hours calling or faxing payers or combing payer portals.

Changing the game with Dental Benefits Advisor

Improving Dental Eligibility and Benefit Verification

Recognizing the need for a cutting-edge alternative, Change Healthcare launched an integrated API solution, Dental Benefits Advisor, in January 2022.

Dental Benefits Advisor instantly offers benefits and coverage according to procedure codes and treatment plans.

This solution has unmatched connectivity with payers and the system leverages historical eligibility, claims, and ERA data.

How Dental Benefits Advisor works

With the solution, providers first send patient information to the payer, who verifies active patient coverage. The system asks providers to correct patient information if payers can’t verify the patient’s coverage.

Next, because the Dental Benefits Advisor 270 Transaction Set includes procedure-specific nodes, the payer’s 271 responses include benefit information for many procedures, relative to plan-specific guidelines.

Dental Benefits Advisor will enable the dental industry to surpass the medical field and fully adopt EDI processes for eligibility, benefit verification, and cost transparency.”

This includes the estimated insurance amount and patient responsibility, along with any limitations or exclusions that may impact reimbursement amounts for each procedure code.


Dental Benefits Advisor will finally enable the dental industry to catch up to the medical field and fully adopt EDI processes for eligibility and benefit verification.

Here are a few of the key benefits:

  • A higher bottom line for dental providers, with fewer insurance denials and potential write-offs, less balance billing, and more upfront payment collection from patients.
  • Less overhead, thanks to the elimination of 80% or more of manual processes involved in eligibility workflows.
  • Happier patients, who will receive accurate information upfront and not be billed the wrong amounts.

Improved Processes for the Dental Industry

Now that eligibility and benefit verification has been streamlined, the dental industry can catch up with the medical industry. Dental providers can use this new technology to improve their workflows and businesses.

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