Edit Insurance Plan Window
The Edit Insurance Plan window opens when you Enter an Insurance Plan for a patient or when you double click an existing plan in the Family module. It also shows when you double click a plan in the Insurance Plan List, though the window may look slightly different.
The window is divided into four main sections:
Default options can be set in Family Module Preferences. Below is a detailed explanation of the fields in each section.
This information is specific to the patient. In the database, it is stored in a table called 'patplan'. The background color is set in Definitions, Misc Colors, Family Module Coverage. If you are editing a plan which is not attached to any patient as current coverage, this upper section may be blank.
- Relationship to subscriber: This is a required field. If the patient is the subscriber, the default is 'Self'. Otherwise there is no default.
- Optional Patient ID: This is no longer used by insurance companies in the U.S. As of 1/1/2012, carriers have generally switched to each patient being their own subscriber rather than having a subscriber ID and a patient ID. This means that you will need to drop some patients from their family's plan and recreate them with subscriber as self, using the patient ID instead of the subscriber ID. Do not do this until you are ready to start sending Electronic Claims in 5010 format.
- Drop: Remove a plan when a patient changes carriers or no longer has insurance coverage. Dropping a plan does not delete the plan; it will still appear in the Insurance Plan List when Plans for Family is clicked under the Add Insurance dropdown. See Dropping an Insurance Plan.
- Patient Plan ID: A system generated unique identifier that is useful for third party reporting.
- Order: Determines the order this plan will show in the Family module (primary, secondary, or supplemental insurance). 1 = primary, 2 = secondary, etc. The number can be changed at any time.
- Eligibility Last Verified: Indicates the date that patient insurance eligibility was marked 'verified' (manually or using the Insurance Plan Verification List). Click Now to insert today's date.
- Pending: Identifies insurance information that is incomplete or unverified. It is informational only and does not change any functionality of the program. If you want to signify that the patient has insurance, but don't even know the name of the insurance company, create a dummy carrier called 'Pending'. Check this box, then come back later and fix it.
- Adjustments to Insurance Benefits: Enter any benefit amounts that have already been used this year, e.g. if the patient had treatment done at another office, or if you have just had a data conversion. Click Add to adjust benefits for amounts used so far. Negative numbers are allowed in the Insurance Used field to indicate rollover amounts available from previous year. This amount will automatically clear when a new benefit year begins.
Insurance Plan Information
This information is specific to the insurance plan and can only be edited by users with the Insurance Plan Edit Permission. Any changes made to the insurance plan will usually change the plan for all subscribers. This functionality is dictated by the two radio buttons in the lower right.
- Change Plan for all subscribers: We recommend this as the default to prevent spawning of duplicate insurance plans.
- Create New Plan if needed: Only select if you need to create a new plan. A value must change in one of the Insurance Plan Information Fields. If no changes are made, a new plan will not be created. Changing Benefit Information will not trigger a new plan (with the exception of 'benefit year'). Changed benefits are at the plan level and apply to all subscribers.
Note: If changes to one of the Insurance Plan Information Fields of an existing plan are set to 'Create New Plan' based on the radio button setting, close the Edit Insurance Plan window before adding or editing benefit information for the new plan (click OK, reopen the new plan, then double click to edit Benefit Information). If you do not and simply edit benefit amounts, any benefit changes will apply to both the new plan and all subscribers of the original plan.
The default radio button setting is set in Setup, Module Preferences, Family tab, 'InsPlan option at bottom, 'Change Plan for all subscribers', is default'. This option should normally be checked.
Options and fields are described below.
- Audit Trail: View insurance carrier changes made to this insurance plan.
- Pick From List: Select an existing insurance plan from the Insurance Plan List.
- Insurance Plan ID: A system generated unique identifier that is useful for third party reporting and to filter the Insurance Plan List.
- Medical Insurance: Check this box if this is Medical Insurance rather than dental. This box is only visible if Medical Insurance is turned on in Show Features.
- Employer: Optional. Will also be added to the Employer List.
- Carrier: Required. Click […] to pick an existing carrier from the Insurance Carrier List or enter carrier information manually. If you manually enter carrier information that doesn't exactly match an existing carrier, or if you change carrier information, a new entry is automatically added in the insurance carrier list.
Note: If you have the InsPlanEdit permission and change information in any carrier field, a new carrier is created. Also, if another user has a plan open with the same carrier, and carrier information is edited by a user with the InsPlanEdit permission, a new carrier is created.
- Electronic ID/Payer ID: Provided by the insurance company if they accept E-claims. Enter the ID manually or click Search ID to search the Payer ID list. If the carrier does not accept electronic claims, you have two choices.
- Leave the ID blank and submit the claims electronically anyway. If the clearinghouse cannot match the insurance carrier name with a known name, the claim will be printed by the clearinghouse and mailed.
- Check Don't Usually Send Electronically. When Sending Claims, these claims will be marked as 'Paper'.
- Other Subscribers: The number of subscribers who use or have used this plan. Click the down arrow to see other subscriber names.
- Plan Type: There are four choices. See Types of Insurance Plans for more information.
- Category Percentage: Traditional percentage insurance plans.
- PPO Percentage: Preferred Provider Organizations. To set this as the default for new plans, see Family Module Preferences.
- Medicaid or Flat Co-pay: All categories will be computed at 100% coverage. Disables all other percentages.
- Capitation: HMO and DMO type plans. Disables all other percentages.
- Other Plan Options
- Use Alternate Code: If the insurance plan uses alternate procedure codes, as some Medicaid plans do, check this box to use those codes when submitting claims. Alternate procedure codes (Alt Code) are defined on the Edit Procedure Code window.
- Don't substitute code (e.g. posterior composites): Check this box to not use substitution codes when estimating insurance payments (e.g. is a plan that doesn't downgrade composites). Substitution codes (Ins. Subst Code) are defined on the Edit Procedure Code window. See Procedure Downgrades.
- Claims show UCR fee, not billed fee: Check this box to show the UCR fees of the treating provider on claims instead of the insurance fee. This is useful when using the Category Percentage type for PPOs, but not necessary when using PPO Percentage type for PPOs, or if this insurance is not PPO. To set the default value as checked for new plans, see Family Module Preferences.
- Hidden: Hide this insurance plan in the Insurance Plan List so it can't be copied for use by other subscribers. If this plan has multiple subscribers, and you want to hide it for all subscribers, you must also select the Change Plan for all subscribers radio button.
- Fee Schedule: The Fee Schedule used by this plan. If 'none', the Provider's fee schedule is usually used. The only exception is if a fee schedule has been set on the Edit Patient window (e.g. a discount/cash fee schedule); this overrides other fee schedules.
- Claim Form: The form used for printed claims. It does not affect e-claims. See Claim Forms to set the default claim form or for information about importing, adding, and editing forms.
- Other Fee Schedules: See Insurance Plan Types for more information.
- Patient Co-pay: Used for patient co-pays per procedure.
- Carrier Allowed: Used for out-of-network fee schedules.
- COB Rule: Select a Coordination of Benefits rule option. Set the default option for new plans in Family Module Preferences.
- Filing Code: For e-claims. If the carrier has an Insurance Filing Code, select it. By default 'Commercial Insurance' is used. If the filing code is incorrect, then the carrier will reject the claim.
- Filing Code Subtype: If the insurance filing code has a specific subtype, select it.
- Claims show base units: Usually applies to medical insurance claims only. Base units are entered on the Procedure Code Edit window. Check this box to show base units on claims.
- Plan Note: Enter notes specific to the insurance plan. This note will show for all subscribers on the plan. These appear in bold red in the insurance grid.
- Label: Print the insurance carrier name and address on an individual mailing label.
- Delete: If the plan has only one subscriber, this will delete the plan (remove it from the Insurance Plan List). If there are other subscribers, the plan will only be removed from this subscriber and associated family members on the plan.
The subscriber is set when first creating the insurance plan. To change the subscriber, click Change.
- Subscriber ID: Required and cannot be blank. The SSN entered on the Edit Patient Information Window - Other Tab is automatically used as the ID, but it can be manually changed. If the patient has Medicaid, use the Medicaid ID number, then also fill in the Medicaid ID on the Edit Patient Information window.
- Effective Dates: Optional and informational only. The end date does not terminate the plan; you must Drop a plan to not use it. Set benefit renewal dates (calendar year or service year) in the Benefit Information section.
- Release of Information: Check this box if the patient has signed a form that states that the patient consents to the use and disclosure of protected health information to the insurance company in order to carry out payment activities. 'Signature on File' will show in box 36 of the claim form.
- Assignment of Benefits: Check this box if the patient has signed a form that states that they authorize and direct payment of the dental benefits, otherwise payable to the patient, directly to the dental office. For offices that make patients pay up front, and the insurance checks get mailed to the patient, uncheck this box. If this box is disabled, the user does not have permission to change this setting (see Permissions, 'Insurance Plan Change Assignment of Benefits'.)
- Notes: Notes specific to the subscriber and associated family members. These appear in bold red in the insurance grid.
Benefit information can only be edited by users with the Insurance Plan Edit Permission.
- Request Electronic Benefits: If you have set up Electronic Benefits with a clearinghouse and a Subscriber ID is entered, click Request to request benefit information or History to view a history of requests.
- Import Benefits:
- If you have set up Trojan, Click Trojan to copy exported Trojan data. The Trojan ID number shows at the right.
If you have set up Insurance Answers Plus, the IAP shows.
- Click Note to view benefit notes if available. They are created when importing benefits and usually read only.
- Benefits Last Verified: Indicates the date that insurance benefits were last marked 'verified' (manually or using the Insurance Plan Verification List). Click Now to insert today's date.
- Don't Verify: Check this box to always exclude this plan from the Insurance Plan Verification List. To also exclude patients with this plan, see Insurance Verification Setup.
- Benefit Information: Double click the grid to enter benefit information on the Edit Benefits window.