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Insurance Remaining Estimates

This page explains how insurance remaining estimates are calculated. To view the information, go to the Treatment Plan module, lower right, or in the Account module hover over Ins Rem.  Calculations consider the current benefit year only. 

There are two columns:

  • Primary:  Calculations for the first (primary) insurance plan listed in the Family module (order of 1).
  • Secondary:  Calculations for the secondary insurance plan listed in the Family module (order of 2).

Procedure estimates are found on the Procedure Info - Financial tab.

Family Insurance
Annual Max: The family’s annual maximum.  Usually this value is entered in the Family column, Annual Max field on the Edit Benefits window, Simplified View. In the Benefit Information grid, this value corresponds to the benefit that matches the following criteria:

  • Level = Family
  • Type = Limitation
  • Time Period = Calendar Year or Service Year
  • Quantity = 0
  • Qualifier = None
  • Proc Code = None (blank)

If no benefit matches the criteria, the box will be blank.  If there are multiple benefits that meet the criteria (e.g. annual maximums for specific categories), the lowest amount shows.

Fam Ded: The family’s general deductible. Usually this value is entered in the Family column, General Deductible field on the Edit Benefits window, Simplified View.  In the Benefit Information grid, this value corresponds to the benefit that match the following criteria:

  • Level = Family
  • Category = None or General
  • Type = Deductible
  • Time Period = Calendar Year or Service Year
  • Quantity = 0
  • Qualifier = None
  • Proc Code = None (blank)

If no benefit matches the criteria, the box will be blank.  If there are multiple benefits that meet the criteria (e.g. general deductibles for specific categories), the deductible entered first shows.

Individual Insurance
Annual Max: The patient’s annual maximum. Usually this value is entered in the Individual column, Annual Max field on the Edit Benefits window, Simplified View. In the Benefit Information grid, this value corresponds to the benefit that match the following criteria:

  • Level = Individual
  • Type = Limitation
  • Category = None or General
  • Time Period = Calendar Year or Service Year
  • Quantity = None
  • Qualifier = None
  • Proc Code = None (blank)

If no benefit matches the criteria, the box will be blank. If there are multiple benefits that meet the criteria (e.g. annual maximums for specific categories), the lowest amount shows.

Deductible: The patient’s general deductible. Usually this value is entered in the Individual column, General Deductible field on the Edit Benefits window, Simplified View.  In the Benefit Information grid, this value corresponds to the benefit that match the following criteria:

  • Level = Individual
  • Category = None or General
  • Type = Deductible
  • Time Period = Calendar Year or Service Year
  • Quantity = 0
  • Qualifier = None
  • Proc Code = None (blank)

If no benefit matches the criteria, the box will be blank.  If there are multiple benefits that meet the criteria (e.g. general deductibles for specific categories), the deductible entered first shows.

Ded Remain: The remaining deductible (family or individual) for the current benefit year. The lowest of the two amounts shows. Only Claim Procedures with status of ‘Adjustment’, ‘NotReceived’, ‘Received’, and ‘Supplemental’ are considered. Each calculation is shown below.

  • ‘Fam Ded’ - (all deductibles applied to any family member) = family ‘Ded Remain’
  • ‘Deductible’ – (all deductibles applied to the current patient) = individual ‘Ded Remain’

Ins Used: The patient’s total insurance used for the current benefit year. Only Claim Procedures with status of ‘Adjustment’, ‘NotReceived’, ‘Received’, and ‘Supplemental’ are considered.  If a benefit meets the following criteria it does not affect this calculation:

  • Type = Limitation
  • For a category other than None or General OR for a specific Procedure Code in a category
  • Time Period = Calendar Year, Service Year, or Lifetime
  • Quantity = 0
  • Qualifier = None

Pending: The patient’s total amount of pending insurance.  Only Claim Procedures with status ‘NotReceived’ are considered. If a benefit meets the following criteria it does not affect this calculation:

  • Type = Limitation
  • For a category other than None or General OR for a specific Procedure Code in a category
  • Quantity = 0
  • Qualifier = None
  • Time Period = Calendar Year, Service Year, or Lifetime

Remaining: The patient’s remaining insurance amount. The calculation is shown below.

  • individual Annual Max – (Ins Used + Pending) = Remaining

Insurance Used vs Pending
If you drop an Insurance Plan, then add a new identical plan, Ins Used and Pending will appear to show show incorrect amounts if the dropped plan is associated with any paid or pending claims in the current benefit period.  This is because claims associated with the dropped plan are not used in the calculations.  To adjust the amounts, follow these steps.

  1. For the new plan, add an Adjustment to Insurance Benefits on the Edit Insurance Plan window. Enter the total insurance that has been paid to date, and the total deductible that has been used.
  2. In the Account module, review all sent Claims and collect data for any claims attached to the dropped plan that are still outstanding.
  3. Delete outstanding claims attached to the dropped plan. 
  4. Recreate the Claims for the new plan.

 

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