Insurance Benefits  

In the Ins Plan Edit window, there is a section at the lower right that stores the plan benefits.

Every benefit stored as a row in the database. The reason why we do it this way is because this is exactly how the data come in from the insurance companies as the dental industry gradually moves to electronic benefit requests. This will allow you to have accurate benefit information on demand without making any phone calls, saving you huge amounts of time.

Click the Edit Benefits button.

Enter all your amounts in the boxes at the top. Keep in mind that leaving a box blank is not the same as entering a zero. Blank indicates that the amount is unknown. If you leave the Annual Max blank, then no calculations can be done to indicate how much is remaining in the Treatment Plan module.

The Calendar Year checkbox at the top applies to all the benefits in the window.  The simplified View box at the top should remain checked unless you are in a foreign country and are not using the typical American settings.

Fluoride Estimates

There are 3 distinct issues with fluoride estimates:

1. Fluoride To Age: This box only applies to child fluoride, code D1203.  If that specific code is treatment planned, then this age value will determine at what age it is no longer covered.  It can be set to 99 to indicate that child fluoride is always covered.  Remember that this value will not affect adult fluoride.  The solution to this problem will be to add code range capabilities, which is Feature Request #1611. In the meantime, you can manually add a Benefit in the Other Benefits section for adult fluoride that looks like this:

In the Quantity box at the middle left change the age limit for adult fluoride.

2. Child vs. Adult: Procedures get automatically created on a recall appointment according to the Recall Type. If the patient is less than 12, then it is considered a child recall.  There is currently no way at all to change that age.  This is Feature Request #352. 

3. Autocodes: Autocodes help to automate procedure entry, especially on Procedure Buttons.  An age condition would be nice there, but is lower priority.

Other Benefits

You can usually ignore the Other Benefits list. There are a few situations where it is useful:

1. You want to override a procedure or category benefit percentage for a particular patient but not everyone on the plan. This can be necessary when you have an incentive plan, and each family member is at a different percentage.
2. You want a particular procedure to be covered at a different percentage, outside of the normal categories. For instance, you want nitrous oxide to not be covered (0%), even though other procedures in that Insurance Category would be covered at, say, 50%.
3. You have different categories (usually this means you are not in the United States of America) so you do not have the category entry boxes in the main benefit area. In this case you will make an entry for each of your self-defined insurance categories.
4. Some preventive work does not apply toward regular annual max.  Examples include CHIP and a number of Medicaid plans.

For any of these, click the Add button.

Choose a category (or None and type in code like D1234), choose 'CoInsurance' for Type, put in the percentage of coverage.  If it is the first situation where the family member is different, check the patient override checkbox. In any case leave all other boxes on the form as they are.  Click OK.

Notes

Certain types of benefits are not easily codified, so they do not yet have a box. These types of benefits are just entered as subscriber notes for now. Examples of benefits which get entered as notes are:

Missing tooth exclusion (a clause that states that if a tooth was extracted before the patient became insured through them, that they will not cover any replacement teeth including a partial or a bridge)
Wait on major treatment (usually 6 months to a year)
Coordination of benefits.

Advanced users might be interested in the Benefit Calculation Logic.