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.
- Simplified View (default): This view allows quick data entry and organizes benefit information by field. See below for a description of each field.
- Row view: If Simplified View is unchecked, benefits are represented by rows. See Insurance Benefit Information - Row View. This is useful if you don't use typical insurance categories (e.g. are in a country other than the U.S. or Canada).
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.
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.
- If plan follows calendar year (starts in January; ends in December): Check this box.
- If the plan follows a service year (starts in a month other than January): Uncheck the box, then enter the two-digit month when benefits renew in the Month field (e.g. October = 10, February = 02).
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.
- Individual: Enter the amount for the individual. If the Family deductible has already been met, the individual deductible will not be applied.
- Family: Enter the amount for the entire family.
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).
- Percentages: The percent covered per procedure for each category. For quick entry of the same percentage amount, enter the amount under Quick% and it will automatically populate the associated fields to its left.
- Deductibles (if different): The deductible per individual or family for a specific category, if it is different than the General Deductible. Zero indicates there is no deductible at all. If blank, the General Deductible is used. See Deductible Examples.
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:
- Every # Years: Every 2 years
- # Per Year: 2 per year
- Every # Months: Every 2 months
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:
- BWs: D0272, D0274
- Pano/FMX: D0210, D0330
- Exams: D0120, D0150
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.
- Lifetime Max: The maximum orthodontic benefit. This is separate from the individual and family Annual Max above as long as the insurance category spans are set correctly. The correct setup (and default) is to have an Ortho span of D8000 to D8999 and to exclude that span from the General category.
- Percentage: The percentage per procedure that is covered. This will affect insurance estimates.
- Ortho Through Age: Used with codes that fall into Ortho insurance category span. This will affect insurance estimates.
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:
- Missing tooth exclusion (a clause that states that if a tooth was extracted before the patient became insured through them, that they will not cover any replacement teeth including a partial or a bridge).
- Wait on major treatment (usually 6 months to a year).
Benefit Calculation Logic
Advanced users might be interested in the Benefit Logic.