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 pays 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).

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.

Ortho: Enter orthodontic benefit information.


Frequency Limitation Benefits: Enter insurance frequency limitations in the grid. Any Code Groups that have been created are listed in the grid by default. Additional benefits can be created as needed. See Frequency Limitations for more detailed information.

Other Benefits: Benefits that are specific to this insurance plan. Useful for incentive plans, or to override typical insurance percentages or amounts. See Other Benefits section 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. This text box supports Right-Click Options.

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.

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.


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%.

Consideration of Other Procedures

Benefits are calculated one procedure at a time, however it may be necessary to consider benefits applied to other procedures. Time spans can be large, and information may be considered from multiple patients. For example, when calculating an ortho lifetime max, it is necessary to consider all procedures, regardless of treatment date, and a family annual max requires considering procedures from all patients under the same subscriber. When considering other procedures:

For Frequency Limitations, procedures affect frequency once attached to a claim. If the claim is denied (i.e., insurance pays $0), the procedure is no longer considered. If a claim is initially denied and a pending supplemental or supplemental payment is entered later, the procedure again affects Frequency Limitation. Dates entered into Insurance History are also be considered. Completed procedures not attached to a claim are not considered.