Custom benefits can be entered on an insurance plan to calculate procedure estimates and insurance remaining estimates.

In an Insurance Plan, at the lower right, is the Benefit Information.

This area is an overview of the benefits that have already been added to an insurance plan.

See Insurance Benefits Overview for additional information, including other areas of the program that affect inusrance benefits.

Edit Benefits

Double-click anywhere in the Benefit Information grid in the Edit Insurance Plan window to make changes to benefits or add new benefits.

Users without the Insurance Plan Edit security permission can open this window. The Insurance Plan Edit is required to save changes or add Other Benefits.

Simplified View

Check or uncheck the Simplified View checkbox to determine the view option of the Edit Benefits window.

There are two view options:

• Simplified View (default): This view allows quick data entry and organizes benefit information by field. The fields for Simplified View are described on this page.
• Row view: If Simplified View is unchecked, benefits are represented by rows. This is useful if typical insurance categories are not used (e.g., are in a country other than the U.S. or Canada). See Edit Benefits - Row View for more information on this view.

In Simplified View, click into a field to enter values. Blank values are considered unknown. Entering 0 will affect benefits. (e.g., entering 0 for a percentage indicates the category is not covered).

Basic Plan Information

In the top-left area, set basic plan information for benefit year, annual max, and deductible.

Benefit Year: (This area is the same between Simplified View or Row View.) 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 insurance pays in benefits per individual or family. If left blank, Insurance Remaining Calculations cannot be done.

• Individual: Enter the annual max amount for the individual.
• Family: Enter the annual max amount for the entire family. Leave blank if If there is no Family Annual Max for the plan.

General Deductible: The amount the individual or family must pay out of pocket before the insurance company begins to pay. Applies to procedures in any Insurance Category. See Insurance Categories for details. Resets at the start of the new service or calendar year.

• Individual: Enter the deductible amount for the individual. If the Family Deductible has already been met, the Individual Deductible is not applied.
• Family: Enter the deductible amount for the entire family. If the Family Deductible has been met by a family member or combination of family members, Individual Deductibles are no longer applied. Leave blank if there is no Family Deductible for the plan.

Categories

In the Categories area, set percentage benefits, deductibles, and waiting periods for default categories.

For benefits entered in this area to be functional, one of each e-benefit category must be assigned to an insurance category in Insurance Categories.

Percentages (%): The percent covered per procedure for each category.

• For quick entry of the same percentage amount, enter the amount in the Quick % box. Values are automatically populated in the associated % fields.

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 except for X-Rays which uses Diagnostic. See Deductibles.

Waiting Periods (if applicable): The number of months a patient must wait before insurance covers a procedure.

• An effective date must be entered in the Insurance Plan, Subscriber Information for waiting periods to calculate.

Age Limits

Set Age Limitations for pre-determined Code Groups in this area.

Options shown in this area determined by Code Groups setup. Only Code Groups marked Show In Age Limits are listed.

Enter a number in a row to create a limitation based on a maximum age. Functions as a through age for the corresponding (e.g., if entering 13, a patient who is 13 years old is still covered, but once they turn 14, they are no longer covered).

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 affects insurance estimates.

Ortho Through Age: Used with codes that fall into Ortho insurance category span. This affects insurance estimates. 0 is not a valid entry.

Frequency Limitation Benefits

Enter insurance frequency limitations in the grid.

Any Code Groups that have been created are listed in the grid by default. Additional benefits can be created as needed. See Frequency Limitations for more detailed information.

Other Benefits

This grid displays additional customizable benefits for this insurance plan.

Other Benefits can be added for benefits that do not fit into preexisting fields or categories in the Edit Benefits window. This may be useful for incentive plans or to override typical insurance percentages or amounts.

Other Benefits can be viewed and edited from this area.

• Some rows are listed by default.
  • Code Groups marked as Show in Other in Code Group Edit. These rows are green.
  • Insurance Categories with a default percentage and no assigned E-Benefit category (e.g., custom categories)
• Click into a cell to make changes to an existing benefit or click Edit on an existing row to open Edit Benefit and make changes.
• Click Add to create a new benefit. Opens Edit Benefit.

Benefits are validated when clicking Save in the Edit Benefits window. If there is an error, a message is shown and applicable rows are highlighted yellow.

Notes and Save

At the bottom, is a notes area and a save button.

Notes: This is the same as the subscriber note on the Edit Insurance Plan window. Certain types of benefits that just affect the subscriber are not easily codified, so do not have a box. These types of benefits are just entered as subscriber notes. This text box supports Right-Click Options.

Click Save to exit the window and see changes in the Edit Insurance Plan window. Users must also click Save from the Edit Insurance Plan window to keep changes to benefits in addition to any other changes to the plan.