Yearly maximum reached: what it means and what to do
The plan pays up to a set dollar amount per benefit year, often $1,000 to $2,000. Once it has paid that much, it pays nothing more until the year renews.
- “Annual maximum met”
- “Benefit maximum reached”
- “Maximum benefit has been paid”
What to check first
- How much of the maximum was used, and by which claims. A claim from another office can use it up.
- When the benefit year renews. It isn't always January.
- Whether this service counts toward the maximum. Some plans don't count preventive care.
What to do
If the plan's numbers are right, the patient owes the fee. If a claim was counted wrongly, ask the insurer to correct it.
Stop it next time
Read the maximum left before quoting. For large treatment, consider splitting it across two benefit years.
Next steps
- Billing guide: crowns
Insurers word these differently, and many print a numbered reason code too. Read the words on the explanation of benefits; they say which of these it is.
Sources
Read November 11, 2026. Where a source describes one insurer's plans, we say so.
Get the patient's share in dollars, from the benefits page
Most denials can be seen coming on the benefits page. Tabruns reads the coverage, deductible, yearly maximum, waiting periods and frequency limits from the insurer's portal and works out what the patient owes. Patient details stay on the office computer.
Not ready? Try the free patient portion calculator.
Other denials
- Frequency limit reached
- Waiting period not met
- Not a covered benefit
- Alternate benefit applied
- Included in another procedure
- More information needed
- Patient not covered on the date of service
- Other insurance information needed
- Filed after the deadline
- Missing tooth clause
- Not supported by the records
- Replacement too soon
- Applied to deductible