Benefits

Custom benefits can be entered on an insurance plan to calculate procedure estimates and insurance remaining estimates.

In an Insurance Plan, at the lower right, is the Benefit Information.

Benefits apply to all subscribers on the plan. If different subscribers have different benefits, create different plans. If a user changes benefits for a plan, all Claim Procedures ( claimprocs ) estimates also change, including those on current and sent claims. Sent claims need to be recalculated before changes affect claim estimates.

To change or view benefits, double-click anywhere in the grid. To change benefit information, the Insurance Plan Edit security permission is required.

There are two view options for the Edit Benefit window.

Benefit Year: (This area is the same between Simplfied View or Row View.) The renewal date used to calculate benefits and the current benefit year. It applies to all benefits in the window.

Note: Every benefit is stored as a row in the database. This format matches how electronic benefits from insurance companies are received.

Simplified View

The fields that show in Simplified View are described below. Click in a field to enter values. Leaving a box blank is different than entering a zero; blank means unknown.

Note: Insurance Categories must have at least one of each e-benefit category present (Accident, Crowns, Diagnostic, Endodontics, General, MaxillofacialProsth, OralSurgery, Orthodontics, Periodontics, Prosthodontics, Restorative, RoutinePreventive, and DiagnosticXRay).

Annual Max: The maximum annual amount insurance will pay in benefits per individual or family. If left blank, Insurance Remaining Calculations cannot be done.

General Deductible: The amount the individual or family pays out of pocket before the insurance company will begin to pay. Applies to procedures in any Insurance Category. See Insurance Categories for details. Resets at the start of the new service or calendar year.

Note: The deductible is applied before the insurance estimate is calculated. For example, if there is a $125 filling covered at 80% and the individual deductible is $50, the insurance estimate is $60 ($125 - $50 deductible x 80%) and the patient portion is $65 ($50 deductible + $15 amount left over after insurance).

Categories:

Fluoride Through Age: Creates an age limitation for fluoride procedures. Bases estimates off codes entered in Insurance Frequencies. 0 is not a valid entry.

Sealants Through Age: Creates an age limitation for sealant procedures. Bases estimates off codes entered in Insurance Frequencies. 0 is not a valid entry.

Frequencies: Enter Frequency Limitations for Bitewings, Pano/FMX, and Exams. Select a frequency type from the dropdown then enter a value in the text box. If 2 is entered in the text box, the dropdown options create the following frequency limitations:

Click More to add Frequency Limitations for additional Code Groups.

For each procedure code or additional Code Group with a frequency limitation, a row displays in the Family Module, Insurance Plan area for reference.

Ortho: Enter orthodontic benefit information.

Other Benefits: Benefits that are specific to this insurance plan. Useful for incentive plans, or to override typical insurance percentages or amounts. See below for more information.

Notes: This is the same as the subscriber note on the Edit Insurance Plan window. Certain types of benefits that just affect the subscriber are not easily codified, so do not have a box. These types of benefits are just entered as subscriber notes.

Other Benefits

There are different types of Other Benefits. These are discussed below. Only specific Other Benefit scenarios are functional. For more information, see, Other Benefits.

ActiveCoverage: Informational only. Not normally used. Used to show a patient has coverage, but without any specific information (e.g., percentage).

Percentage (CoInsurance): Percentage insurance will cover of a certain procedure or category.

Deductible: Dollar amount the individual or family must pay before insurance coverage begins.

CoPayment: Informational only. Patient portion owed for a procedure. Copayments should be entered into a copay fee schedule instead. Any copays entered into insurance benefits are non-functional. See: Fee Schedules for more information.

Exclusions: Services that are not covered by insurance. These can be procedure categories or individual codes.

Limitations: Includes multiple limitation types such as maximums frequency or age.

Waiting Period: Time period after the insurance effective date the insured must wait prior to insurance covering a benefit.

Benefit Hierarchy

Benefits are calculated one procedure at a time. Multiple benefits can apply to a single procedure code. If some benefits are of the same type, there is a hierarchy to determine which benefits affect insurance estimates.

1. Benefits applied to the specific procedure code.

2. Benefits applied to an Insurance Category containing the procedure code. If the procedure is included in multiple categories, benefits for categories lower in the list take higher priority.


Example:

If D4910 is in both the General and Perio categories, the Perio benefit supersedes the General benefit, because the category is more specific (lower in the Insurance Categories list). If no other benefits existed for the procedure, insurance would cover the procedure at 80% Perio rate, not the 70% General rate.

Because there is a benefit specifically for D4910, this supersedes the benefits for any category. Even though D4910 is included in the Perio and General categories, the procedure will actually be covered at 100%.