Dental exams and insurance
How plans usually pay for periodic, comprehensive and problem-focused exams, how often, and why an exam claim comes back unpaid.
Exams sit in the preventive and diagnostic group, which plans in the common 100-80-50 structure pay at 100%, usually without the deductible. The catch is how often.
Typical limits
| Kind of exam | Often limited to |
|---|---|
| Periodic (recall) exam | 2 a year |
| Comprehensive exam | 1 every 3 years per provider |
| Problem-focused (limited) exam | Counted on its own on some plans, against the periodic exams on others |
See dental frequency limitations for how plans count: per calendar year, per benefit year, or a number of months since the last one.
Why exam claims come back unpaid
- The frequency limit was already used, often at another office. The claims history only shows what was billed to this plan, so ask new patients when their last exam was.
- A comprehensive exam at a new office after the patient had one elsewhere: some plans count it per provider, others per patient.
- An exam on the same day as other services that the plan treats as including an exam. Plans differ, so check the limitations.
Before the visit
- Find the exam limit on the benefits page, under frequencies or limitations.
- Find the last paid exam in the claims history and count forward by the plan's rule.
- If the exam won't be paid, tell the patient the fee before the visit, not at checkout.
This is how plans usually work, not how every plan works. The patient's own plan documents and the insurer decide what's paid.
Codes you'll see
CDT is a registered trademark of the American Dental Association. Tabruns is not affiliated with or endorsed by the ADA. The descriptions here are our own plain-English summaries, not the ADA's official wording; use your current CDT manual or practice software for the official code set.
Terms on this page
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
Knowing how plans pay for exams is half the job. 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.