Insurance Benefit Information - Simplified View

An overview of insurance plan benefits shows in the lower right of the Edit Insurance Plan Window.

These percentages and amounts are used to calculate procedure estimates and insurance remaining estimates. Benefits apply to all subscribers on the plan. If different subscribers have different benefits, create different plans. If you change benefits for a plan, all Claim Procedures (claimprocs) estimates will also change, including those on current and sent claims.

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.

Note: Every benefit is stored as a row in the database. This format matches how electronic benefits from insurance companies are received. The dental industry is gradually moving towards electronic benefit requests, which will save you time and provide accurate benefit information without any phone calls.

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).

Benefit Year: The renewal date used to calculate benefits and the current benefit year. It applies to all benefits in the window.

Annual Max: The maximum annual amount per individual or family. If left blank, Insurance Remaining Estimate 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 the None or General category and 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 you have 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: Used with code D1208 and D1206.

Frequencies: Plan frequency limitations for bitewings, pano/FMX, and exams. Enter a value, then click the dropdown to select the frequency. For example:

This information affects insurance estimates if Insurance Frequency Limitations is enabled. Set which codes are affected by each limitation in Treatment Plan Module Preferences. The defaults are as follows:

For each procedure code with a frequency limitation, a row will show in the Family module, Insurance Plan area for easy 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. Only specific scenarios are known to work and adding other benefits is rare. See Examples of Other Benefits.

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

Benefit Calculation Logic

Advanced users might be interested in the Benefit Logic.