Edit Insurance Plan Window
The Edit Insurance Plan window opens when you Enter an Insurance Plan for a patient or when you double click an existing plan in the Family module. It also shows when you double click a plan in the Insurance Plan List, though the window may look slightly different.
Detailed explanation of the fields on this window are divided into the following sections:
Default options for this window can be set in Family Module Preferences.
Relationship to subscriber: (required) If the patient is the subscriber, the default is 'Self'. Otherwise there is no default.
Optional Patient ID: No longer used by most insurance companies in the U.S.
Drop: Remove a plan when a patient changes carriers or no longer has insurance coverage. Dropping an Insurance Plan does not delete the plan; it will still appear in the Insurance Plans for Family window.
Patient Plan ID: A system generated unique identifier that is useful for third party reporting.
Order: Determines the order this plan will show in the Family module (primary, secondary, or supplemental insurance). 1 = primary, 2 = secondary, etc. The number can be changed at any time.
Eligibility Last Verified: The date that patient insurance eligibility was marked 'verified' (manually or using the Insurance Plan Verification List). Click Now to insert today's date.
Pending: Informational only. Identifies insurance information that is incomplete or unverified. If you don't even know the insurance company name, create a dummy carrier called 'Pending', check the Pending box, then come back later and fix it.
Ortho: View patient-specific information about the next time an orthodontic claim will be automatically generated when using the Auto Ortho Tool.
Adjustments to Insurance Benefits: Enter any benefit amounts that have already been used this year (e.g. if the patient had treatment done at another office, or if you have just had a data conversion). Click Add to adjust benefits for amounts used so far. The amount automatically clears when a new benefit year begins. See also Adjustments to Insurance Benefits.
Changing a Plan vs Creating a New Plan
Verify the radio button settings before making changes:
Warning: To make changes to an existing plan, see Updating Insurance Plan Information for steps on how to change employers, carriers, or update plan information for all subscribers vs single subscriber, etc. This may help avoid duplication errors.
Plan Info Tab (Insurance Plan Information)
Audit Trail: View changes made to the insurance carrier, insurance plan, benefits, or employer. This audit trail is accessible to all users.
Pick From List: Select an existing insurance plan from the Insurance Plan List. Requires the Change existing Ins Plan using Pick List permission. Alternately, drop the insurance plan before picking a new plan.
Insurance Plan ID: A system generated unique identifier that is useful for third party reporting and to filter the Insurance Plan List.
Employer: Optional. Will also be added to the Employer List.
Carrier: Required. Click […] to pick an existing carrier from the Insurance Carrier List or enter carrier information manually. If you manually enter carrier information that doesn't exactly match an existing carrier, or if you change carrier information, a new entry is automatically added in the insurance carrier list.
Electronic ID/Payer ID: Provided by the insurance company if they accept E-claims. Enter the ID manually or click Search ID to search the Payer ID list. If the carrier does not accept electronic claims, you have two choices.
Other Subscribers: Indicates the number of subscribers who use or have used this plan. Click the down arrow to see other subscriber names.
Plan Type: The type of plan. See Types of Insurance Plans for more information.
Fee Schedule: The Fee Schedule used by this plan. If 'none', the Provider's fee schedule is usually used. The only exception is if a fee schedule has been set on the Edit Patient window (e.g. a discount/cash fee schedule); this overrides other fee schedules.
Other Fee Schedules: See Insurance Plan Types for more information.
Use Alternate Code: Use alternate procedure codes when submitting claims (e.g. Medicaid). To associate alternate codes (Alt Code) with procedure codes, see Editing Procedure Codes.
Substitution code options: These options determine whether or not estimated fees for procedures are downgraded based on substitution codes. Also see Procedure Estimate Downgrades.
To associate substitution codes with procedures, see Editing Procedure Codes.
Claims show UCR fee, not billed fee: Show the UCR fees of the treating provider on claims instead of the insurance fee. This is useful when using the Category Percentage type for PPOs, but not necessary when using PPO Percentage type for PPOs, or if this insurance is not PPO. To set the default value for new plans, see Family Module Preferences.
Hidden: Hide this insurance plan in the Insurance Plan List so it can't be copied for use by other subscribers. If this plan has multiple subscribers, and you want to hide it for all subscribers, you must also select the Change Plan for all subscribers radio button.
Claims show base units: Check this box to show base units on claims. Usually applies to medical insurance claims only. Base units are entered on the Procedure Code Edit window.
Claim Form: The form used for printed claims. Set the default in Claim Form Setup. It does not affect e-claims.
COB Rule: Select a Coordination of Benefits rule option. Set the default option for new plans in Family Module Preferences.
Filing Code: For e-claims. If the carrier has an Insurance Filing Code, select it. By default 'Commercial Insurance' is used. If the filing code is incorrect, then the carrier will reject the claim.
Filing Code Subtype: If the insurance filing code has a specific subtype, select it.
Billing Type: The plan's Billing Type. If the preference in Family Module Preferences for 'New patient primary insurance plan sets patient billing type' is checked, and this is a new primary insurance plan, setting a billing type here will also assign the billing type to the patient on the Edit Patient Information window. (If you change an existing plan's billing type, it will not automatically change the patient's billing type).
If Initial Plus Periodic is the claim type, the following fields are also editable.
Label: Print the insurance carrier name and address on an individual mailing label.
Delete: If the plan has only one subscriber, this will delete the plan (remove it from the Insurance Plan List). If there are other subscribers, the plan will only be removed from this subscriber and associated family members on the plan.
Subscriber ID: Required and cannot be blank. The SSN entered on the Edit Patient Information Window - Other Tab is automatically used as the ID, but it can be manually changed. If the patient has Medicaid, use the Medicaid ID number, then also fill in the Medicaid ID on the Edit Patient Information window.
Effective Dates: Optional and informational only. The end date does not terminate the plan; you must Drop a plan to not use it. Set benefit renewal dates (calendar year or service year) in the Benefit Information section.
Release of Information: Check this box if the patient has signed a form that states that the patient consents to the use and disclosure of protected health information to the insurance company in order to carry out payment activities. 'Signature on File' will show in box 36 of the claim form.
Assignment of Benefits: Check this box if the patient has signed a form that states that they authorize and direct payment of the dental benefits, otherwise payable to the patient, directly to the dental office. For offices that make patients pay up front, and the insurance checks get mailed to the patient, uncheck this box. If this box is disabled, the user does not have permission to change this setting (see Permissions, 'Insurance Plan Change Assignment of Benefits'.)
Notes: Notes specific to the subscriber and associated family members. These appear in bold red in the insurance grid.
Request Electronic Benefits: If you have set up Electronic Benefits with a clearinghouse and a Subscriber ID is entered, click Request to request benefit information or History to view a history of requests.
Benefits Last Verified: Indicates the date that insurance benefits were last marked 'verified' (manually or using the Insurance Plan Verification List). Click Now to insert today's date.
Don't Verify: Check this box to always exclude this plan from the Insurance Plan Verification List. To also exclude patients with this plan, see Insurance Verification Setup.
Benefit Information: Double click the grid to enter benefit information on the Edit Benefits window.
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