This page describes the logic used to calculate benefits. It is very technical.
Kinds of Benefits
There are six different kinds:
Limitation Amount: Maximums, Ortho Lifetime maximums, family, individual, fluoride.
CoInsurance %: For all, for Category, or for one procedure. A matching patplan % always wins over a plan %.
Deductible: General, or for Category. Even for procedure. Family or individual.
Exclusions: Example: cosmetics not covered. $0 coverage.
CoPayment: This is handled in fee schedules instead of in Benefits. Do not use.
Limitation for time period: Exams per year, etc. These are only included in calculations if Insurance Frequency Checking is enabled.
Benefit Types used by Open Dental
ActiveCoverage: Not usually used. Would only be used if you are just indicating that the patient is covered, but without any specifics.
Percentage: aka CoInsurance.
Deductible: Dollar amount.
CoPayment: Do not use.
Exclusions: Services that are simply not covered at all.
Limitations: Covers a variety of limitations, including max, frequency, fee reductions, etc.
Timing of Calculations
Insurance estimate calculations are very complex, so they are only calculated at specific times. These estimates are calculated at the following specific times:
Viewing the Treatment Plan module (all procedures for the patient).
Adding a new procedure.
Editing a procedure.
Creating a claim (the procedures on the claim).
Deleting a claim.
Closing the edit procedure window.
Benefits are calculated on a single procedure at a time. This procedure has a specific procedure code, and only benefits which apply to that code are considered. There can be multiple benefits all applying to a single code. As long as they are of different kinds, there is no ambiguity. If they are of the same kind, then a hierarchy needs to be considered. From broadest to most specific:
Category, top to bottom.
Lower, more specific items in the list always take priority over broader ones higher up if they are of the same kind.
Awareness of other Procedures
Even though benefits are calculated on one procedure at a time, there frequently comes a moment in the calculation when it is necessary to know about benefits applied to other procedures. The time span can be large, and information may be needed about multiple patients. For example, an ortho lifetime max needs to know about all procedures, regardless of how long ago they were performed. And a family maximum can require knowledge of procedures from all other family members.
When considering other procedures, completed procedures that have been attached to claims are always considered, whether the actual payment or just the estimated payment. For TP procedures, only those that come "before" the current procedure are considered. The order is as displayed in the TP module.
Frequency limitations: Only procedures on claims that have been sent AND received are considered when calculating estimates.
The internal mechanism for obtaining information about other procedures is as follows. Before starting the calculation, a single query is used to grab a list of objects. Each object contains a date, proccode, ins paid/est, and deductible paid/est. The list contains information from all completed procedures attached to claims as well as adjustments to insurance benefits contained within InsPlans. To keep the list shorter, a date range is calculated first based on the information in the list of benefits. Also, other family members are only included if there are family level benefits. Family members are defined as other patients with the same insurance plan, whether actually in the family or not.
Questions and Answers
Q: In what order are deductibles and annual max applied?
A: Deductibles and annual max are applied in the order that claims are created, not by procedure date.