Benefits

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

These percentages and amounts are used to calculate procedure estimates and insurance remaining estimates. Benefits apply to all subscribers on the plan. If different subscribers have different benefits, create different plans. If a user change benefits for a plan, all Claim Procedures ( claimprocs ) estimates will also change including those on current and sent claims. Sent claims will need to be recalculated before changes affect claim estimates.

There are two view options for the Edit Benefit window.

Note: Every benefit is stored as a row in the database. This format matches how electronic benefits from insurance companies are received. The dental industry is gradually moving towards electronic benefit requests, which will save you time and provide accurate benefit information without any phone calls.

Simplified View

The fields that show in Simplified View are described below. Click in a field to enter values. Leaving a box blank is different than entering a zero; blank means unknown.

Note: Insurance Categories must have at least one of each e-benefit category present (Accident, Crowns, Diagnostic, Endodontics, General, MaxillofacialProsth, OralSurgery, Orthodontics, Periodontics, Prosthodontics, Restorative, RoutinePreventive, and DiagnosticXRay).

Benefit Year: The renewal date used to calculate benefits and the current benefit year. It applies to all benefits in the window.

Annual Max: The maximum annual amount insurance will pay in benefits per individual or family. If left blank, Insurance Remaining Calculations cannot be done.

General Deductible: The amount the individual or family pays out of pocket before the insurance company will begin to pay. Applies to procedures in the None or General category and resets at the start of the new service or calendar year.

Note: The deductible is applied before the insurance estimate is calculated. For example, if you have a $125 filling covered at 80% and the individual deductible is $50, the insurance estimate is $60 ($125 - $50 deductible x 80%) and the patient portion is $65 ($50 deductible + $15 amount left over after insurance).

Categories:

Fluoride Through Age: Creates an age limitation for fluoride procedures. Bases estimates off codes selected in the Treatment Plan Module Preferences. 0 is not a valid entry.

Sealants Through Age: Creates an age limitation for sealant procedures. Bases estimates off codes selected in the Treatment Plan Module Preferences. 0 is not a valid entry.

Frequencies: Plan frequency limitations for categories. Enter a value, then click the dropdown to select the frequency. For example:

More: Click to add additional Benefit Frequencies. The associated procedure codes for each category are set in the Treatment Plan Module Preferences. See: Frequency Limitations for more information.

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

Ortho: Enter orthodontic benefit information.

Other Benefits: Benefits that are specific to this insurance plan. Useful for incentive plans, or to override typical insurance percentages or amounts. See below for more information.

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.

Other Benefits (Benefit Types)

ActiveCoverage: Informational only. Not normally used. Used to show a patient has coverage, but without any specific information (e.g. percentage).

Percentage (CoInsurance): Percentage insurance will cover of a certain procedure or category.

Deductible: 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: Services that are not covered by insurance. These can be procedure categories or individual codes.

Limitations: Includes multiple limitation types such as maximums frequency or age.

Waiting Period: Time period after the insurance effective date the insured must wait prior to insurance covering a benefit.

Note: Only specific scenarios are functional. For more information, see: Other Benefits.

Benefit Hierarchy

Benefits are calculated one procedure at a time. Multiple benefits can apply to a single procedure code. If some benefits are of the same type, there is a hierarchy to determine which benefit will affect insurance estimates.

1. Benefits applied to the specific procedure code.

2. Benefits applied to an Insurance Category containing the procedure code. If the procedure is included in multiple categories, benefits for categories lower in the list take higher priority.


Example:

If D4910 is in both the General and Perio categories, the Perio benefit supersedes the General benefit, because the category is more specific (lower in the Insurance Categories list). If no other benefits existed for the procedure, insurance would cover the procedure at 80% Perio rate, not the 70% General rate.

Because there is a benefit specifically for D4910, this supersedes the benefits for any category. Even though D4910 is included in the Perio and General categories, the procedure will actually be covered at 100%.