Use the Benefits Row view to view each benefit as a line item.
In the Edit Benefits window, uncheck the Simplified View box.
This is useful when you don't use typical Insurance Categories (e.g. in a country other than the U.S. or Canada).
- Simplified View: Check/uncheck the box to switch between Simplified View and Row View.
- Benefit Year: The renewal date used to calculate benefits and the current benefit year. It applies to all benefits in the window.
- If the plan follows calendar year (starts in January and 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).
- Benefits: Each row represents a benefit. Double-click to edit.
- Notes: The same as subscriber notes on the Insurance Plan. Certain types of benefits are not easily codified, so they do not have a box. These types of benefits are just entered as subscriber notes for now. Examples of benefits which get entered as notes are:
- Missing tooth exclusion (a clause that states that if a tooth was extracted before the patient became insured through them, that they will not cover any replacement teeth including a partial or a bridge).
- Wait on major treatment (usually 6 months to a year).
Add or Edit a Benefit
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.
Click Add, or double-click a row to edit.
- Patient Override: Check this box if this is an incentive plan benefit where each family member is at a different percentage. These benefit changes will only affect this patient and this plan.
- Category or Proc Code: Category refers to the insurance category the benefit applies to. To apply to a specific procedure code instead, select None as the category and enter the code.
- Type: Some types affect Insurance Remaining Calculations; others are informational only.
- ActiveCoverage: informational only
- CoInsurance: Affects calculations. Used for percentages, not amounts.
- Deductible: Affects calculations.
- CoPayment: Informational only. To be functional, copays should be added into a Copay Fee Schedule.
- Exclusions: Affects calculations based on the Ins plans with exclusions use UCR fee preference.
- Limitations: Affects calculations for amounts, but not percentages.
- Waiting Period: Affects calculations. Insurance plan must have an effective date entered for calculations to work.
- 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.
- 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 a 12 month period.
- 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.
- None: 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 will cover a benefit.
- Visits: Informational only.
- Years: Affects calculations. Used for waiting periods.
- Months: Affects calculations. Used for waiting periods.
- Coverage Level:
- 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).