A breakdown describes the plan, not the patient. It records what the plan provides — not what this particular patient would be paid for today given their age, their history, or how long they have been enrolled.

This is the single most common reason a value looks wrong at first glance and is actually right. A percentage is never lowered because this patient aged out, already used up their frequency, or has not finished a waiting period yet. Each of those facts is recorded separately, in its own place.

The only parts of a breakdown that describe the patient rather than the plan are the amounts used and remaining, the patient's treatment history, and whether a waiting period has been satisfied.

Percentages are the plan's rate, always. If you see sealants at 100% on a 30-year-old, that is the plan's sealant rate — not a claim that this patient will be paid at 100%. The age cutoff is recorded in the age limitation field, and the reason is spelled out in the note. Read those three things together and you have the full picture.

A percentage is what the plan pays, never the patient's share. Some payer portals display it the other way around. If a portal shows "Patient Pays 20%," your breakdown will show 80%.

0% means the plan covers that service for nobody. A plan that states it does not cover implants, full stop, is a genuine exclusion and 0% is the correct value. "Not covered for this patient" is a different thing and will never be written as 0%.

Percentages are always whole numbers from 0 to 100.

An age limitation appears only when coverage actually changes with age. If a plan lists an under-19 band and an over-19 band and pays the same rate for both, that is not an age limit — it is just how the payer laid out the page. Recording it would invent a restriction that does not exist.

An age that decides who is covered is also not a limit on the benefit. A common example: ortho ends at 26 because that is when dependent coverage ends, while the subscriber has ortho with no age cap at all. The breakdown will show no age limitation for ortho, and the ortho note will explain that ortho is covered for dependents up to the dependent age. If we recorded 26 as an ortho age limit, it would tell you a 30-year-old subscriber cannot get ortho — which is false.

When there is genuinely no age cap, you will see "no age limitation" with the age itself left empty. Payers often use filler ages like 0 or 99 to mean "no cap"; we translate those rather than passing along a meaningless "covered through age 99."

Anything the age field cannot express — "covered to the end of the month they turn 26," for instance — is written out in the note in the plan's own wording.

Waiting periods are recorded even when they have already been satisfied, because it is still a real fact about the plan. A blank would lose it.

A waiting period never changes the coverage percentage. If a service is not covered yet, the breakdown shows the percentage the plan will pay once the wait is served — the waiting period fields carry the "not yet" part. Zeroing the percentage on top of that would say the plan does not cover the service at all, which is a different and wrong fact.

Because a waiting period belongs to the plan and not to a network, you will see it on both in-network and out-of-network benefits.

The maximum shown is the plan's maximum. What this patient has already used, and what is left, are recorded separately as used and remaining amounts.

A deductible of $0 means the plan has no deductible. It is a real answer, not a field someone forgot to fill in.

When a plan has no frequency limit, you will see the count and period left empty with the qualifier set to "No Frequency Limit." That is deliberate, so you can tell "unlimited" apart from "nobody checked." A lifetime limit is always written as 1 lifetime.

Blank means "the plan did not state it." It is a valid answer, and it is different from zero, different from "no limit," and different from a guess.

A code missing from the plan's schedule has unknown coverage, not 0% coverage — so it stays blank. The exception is a plan that says anything not listed is not covered; then 0% is correct, because the plan itself said so.

We also do not calculate values the plan did not state, even when the math is obvious.

The notes carry everything the structured fields cannot hold, in the plan's own wording. A rule like "1 per tooth per 5 years, after a 12-month wait unless replacing an existing crown" goes into the fields as 1 per 5 years, with the full wording in the note — nothing gets dropped. Notes accumulate rather than being overwritten, so detail from a rep call stays put.

If coverage is terminated, the termination date goes in the notes whenever the plan gives one.

Please tell us. Go to the Verifications tab, open the verification, and flag the value as inaccurate. Say what you expected to see and where you saw it — the portal screen, the rep who told you, the fax. That detail is what lets us confirm it fast and fix the underlying source, not just the one breakdown.

Flagged values are genuinely useful to us. Checking the note and the related fields first just means the reports we get are the ones that lead somewhere.