Home User Manual Discussion Forum Search

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.

Detailed explanation of the fields on this window are divided into the following sections:

Default options for this window can be set in Family Module Preferences.

Patient Information
This information is specific to the patient.

  • In the database, it is stored in a table called 'patplan'.
  • Set the background color 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: (required) If the patient is the subscriber, the default is 'Self'. Otherwise there is no default.

Optional Patient ID: No longer used by most insurance companies in the U.S.
Note: In 2012,most carriers switched to each patient being their own subscriber with a subscriber ID. If you plan to send e-claims in 5010 format, you may need to drop patients from their family's plan and recreate them with subscriber as self, using the patient ID instead of the subscriber ID.

Drop: Remove a plan when a patient changes carriers or no longer has insurance coverage. Dropping an Insurance Plan does not delete the plan; it will still appear in the Insurance Plans for Family window.

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: 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: Informational only. Identifies insurance information that is incomplete or unverified.  If you don't even know the insurance company name, create a dummy carrier called 'Pending', check the Pending box, then come back later and fix it.

Ortho: View patient-specific information about the next time an orthodontic claim will be automatically generated when using the Auto Ortho Tool.

  • Fee: Defaults to the fee set on the Ortho tab. To override it for the next claim only, uncheck 'Use Default Fee', then enter the new fee.
  • Next Claim Date: The date the next claim will be created using the Auto Ortho Tool. Defaults to a date based on the last auto-created claim and the frequency (Auto Proc Period).

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. The amount  automatically clears when a new benefit year begins. See also Adjustments to Insurance Benefits.

Changing a Plan vs Creating a New Plan
Two radio buttons in the lower right determine whether plan editing insurance plan information updates an existing plan for all subscribers or creates a new plan.

Verify the radio button settings before making changes:

  • Change Plan for all subscribers: We recommend setting this as the default to prevent spawning of duplicate insurance plans. See Family Module Preferences,  'InsPlan option at bottom, 'Change Plan for all subscribers', is default'. This option should normally be checked
  • Create New Plan if needed: Only select if you need to create a brand 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.

Notes:

  • 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.
  • If an existing plan is selected, the radio button setting is 'Create New Plan', and you make changes to an Insurance Plan Information Fields, close the Edit Insurance Plan window before adding or editing benefit information for the new plan. 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.
    a. Click OK.
    b. Reopen the new plan.
    c. Double click to edit Benefit Information.

Warning: To make changes to an existing plan, see Updating Insurance Plan Information for steps on how to change employers, carriers, or update plan information for all subscribers vs single subscriber, etc. This may help avoid duplication errors.

Plan Info Tab (Insurance Plan Information)
This information is specific to the insurance plan and can only be edited by users with the Insurance Plan Edit Permission.

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. 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 Insurance Plan Edit 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 Insurance Plan Edit 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: Indicates the number of subscribers who use or have used this plan. Click the down arrow to see other subscriber names.

Plan Type: The type of plan. 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.

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.

Other Fee Schedules: See Insurance Plan Types for more information.

  • Patient Co-pay Amounts: Used for patient co-pays per procedure. 
  • Carrier Allowed Amounts: Used for out-of-network fee schedules.

Other Ins Info Tab

Use Alternate Code: Use alternate procedure codes (as some Medicaid plans do) when submitting claims. Alternate procedure codes (Alt Code) are defined on the Edit Procedure Code window.

Don't substitute code (e.g. posterior composites): Do 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: 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 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.

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.

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.

Ortho Tab
The Ortho tab shows when 'Show ortho case in account module' is selected in Ortho Setup. Use it to enter plan information for orthodontic claims.

  • Information can only be changed by users with the Insurance Plan Ortho Edit Permission.
  • This information will also show in the Ortho Case tab.



Ortho Claim Type: Select how the carrier wants to receive orthodontic claims.

  • Initial Claim Only: Send a single orthodontic claim for the initial procedure.
  • Initial Plus Visit: Send an orthodontic claim for the initial procedure and each subsequent visit.
  • Initial Plus Periodic: Send an orthodontic claim for the initial procedure, then send claims periodically for a certain fee and procedure. Selecting this option makes claims for this carrier eligible for automatic claim generation using the Auto Ortho Tool.

If Initial Plus Periodic is the claim type, the following fields are also editable.

  • Ortho Auto Proc: The procedure code to put on auto-generated orthodontic claims. Set the default in Ortho Setup. Click [...] to select a different procedure. Click Default to reset the default. Only the first 5 digits of procedure codes are sent to insurance.
  • Ortho Auto Fee: The procedure fee billed in the claim.
  • Auto Proc Period: How often the claim will be auto-generated (Auto Proc Period).
  • Wait 30 days before creating the first automatic claim: If the insurance carrier requires that you wait a minimum amount of days after the initial visit before sending periodic claims, check this box. When checked, the next claim will show in the Auto Ortho Claim list 30 days after the initial procedure is completed.

Miscellaneous
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.

Subscriber Information
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
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.

 

Open Dental Software 1-503-363-5432