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Insurance Frequency Checking

A procedure's insurance frequency limitations may or may not affect estimates of treatment planned procedures, depending on your preferences. When insurance frequency checking is enabled:

  • Only procedures in claims that have been 'Received' will be considered when calculating estimates based on frequency limitations.
  • In the Treatment Plan module, primary and secondary insurance estimates will consider frequency limitations.
  • When scheduling a procedure that has met its limitation, a warning will pop up.

Example: Frequency limitation for BWs is every 2 years. On 12/28/2016, patient had BWs taken and a claim was sent and received.

In the Treatment Plan module:

  • When the Estimate as of date is 12/29/2018 and later (2 years after completed procedure), BW estimates will indicate it is covered.
  • When the Estimate as of date is 12/28/2018 or earlier (limitation already met), the BW estimate will indicate that the procedure is not covered by insurance.

When scheduling an appointment:

  • If the schedule date is 12/29/2018 or later, scheduling proceeds as normal.
  • If the schedule date is 12/28/2018 or earlier, a warning will pop up indicating a frequency conflict exists. You have the option to proceed or cancel.

Set up and Enable Frequency Checking
Step 1. In Treatment Plan Module Preferences, check Enable Insurance Frequency Checking and select the codes affected by each limitation. The defaults are:

  • BWs: D0272, D0274
  • Pano/FMX: D0210, D0330
  • Exams: D0120, D0150

Step 2. Enter the plan's frequency limitations on the Benefit Info window.

For each frequency limitation procedure code, a row will show in the Family module, Insurance Plan area.

View Estimates for Treatment Planned Procedures
In the Treatment Plan module, click the Estimate as of dropdown and select the date. Click Refresh to update calculations based on the date.

When a procedure is not covered due to a frequency limitation, the procedure's description will indicate it.

 

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