Offices can add custom benefits to insurance plans to account for non-standard benefits.

In the Edit Benefits window, click Add.

Alternatively, double-click an existing benefit from the Benefits or Other Benefits grid to edit.

If using the Simplified View, enter benefits in the fixed rows, Age Limit grid, or Frequency Limitation Benefits grid. Additional benefits can be added manually. If using the Row View (Simplified View is unchecked), all benefits must be added manually.

To see examples of other benefit scenarios that are known to work, see Other Benefits. Adding benefits scenarios that are not listed on the Other Benefits page may be informational only and not affect insurance calculations.

• Patient Override: Check this box if this is an incentive plan benefit where each family member is at a different percentage. These benefit changes only affect this patient and this plan.
• One of the following options can be used to apply the benefit.
  • Category or: Applies to all codes in the selected Insurance Category. Used for Other Benefits.
  • or Proc Code: Applies to a specific procedure code. Used for Other Benefits.
  • or Code Group: Applies to all codes in a specific Code Group.
• Percent: The percentage of coverage for this category or procedure code.
• Amount: Dollar amount. Used for limitations and deductibles.
• Time Period: Some options affect insurance remaining calculations; others are informational only.
  • Blank: No time period. Field is irrelevant to the benefit.
  • Service Year: Affects calculations. For use with service benefit year plans only (plan restarts a month other than January).
  • Calendar Year: Affects calculations. For use with calendar benefit year plans only (plan restarts in January).
  • Lifetime: Affects calculations.
  • Years: Informational only
  • NumberInLast12Months: Affects calculations. For use with Frequency Limitations. Maximum number of services within 12 months.
• Quantity/Qualifier: If there is a frequency limitation or waiting period on a category or procedure, enter a number and select the qualifier that matches.
• Blank: No quantity or qualifier. Field is irrelevant to the benefit.
• Number of Services: Affects calculations. Used for limitations.
• Age Limit: Affects calculations. Used for limitations. Maximum age insurance covers a benefit.
• Visits: Informational only.
• Years: Affects calculations. Used for waiting periods and Frequency Limitations.
• Months: Affects calculations. Used for waiting periods and Frequency Limitations.
• Coverage Level:
  • Blank: No coverage level. Field is irrelevant to the benefit.
  • Individual: Apply this benefit change to all individual subscribers on this plan. Most commonly used for maximums or deductibles.
  • Family: Use when a family has a benefit that is in addition to the individual coverage of the subscriber (e.g. individual preventative benefit is $250 per year, but the family has a total cap of $500). This is used when specific categories of coverage have specific limits.
  • None: For use with benefits that do not specify a limit (e.g., a percentage, copay).
• Treatment Area: For use with Frequency Limitations.
• Type: Some types affect Insurance Remaining Calculations; others are informational only.
  • ActiveCoverage: Informational only. Not normally used. Used to show a patient has coverage, but without any specific information (e.g., percentage).
  • CoInsurance: Affects calculations. Percentage insurance covers for a certain procedure code, category, or code group. Not used for amounts.
  • Deductible: Affects calculations. Dollar amount the individual or family must pay before insurance coverage begins.
  • CoPayment: Informational only. Patient portion owed for a procedure. Copayments should be entered into a copay fee schedule instead. Any copays entered into insurance benefits are non-functional. See Fee Schedules for more information.
  • Exclusions: Affects calculations based on the Ins plans with exclusions use UCR fee (zero out write-offs) in Preferences. Services that are not covered by insurance. These can be categories, code groups, or individual codes.
  • Limitations: Affects calculations for amounts, but not percentages. Includes multiple limitation types, such as maximums, frequency, or age.
  • Waiting Period: Affects calculations. ime period after the insurance effective date the insured must wait prior to insurance covering a benefit. Insurance plan must have an effective date entered for calculations to work.
• Teeth (for exclusions or age limitations): Tooth numbers or tooth ranges can be entered here when defining age limitations or exclusion benefits. Tooth range entry is only supported for Universal nomenclature; other nomenclatures need to list each individual tooth instead.