Insurance Plan

The Edit Insurance Plan window opens when you Add Insurance 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 explained below.

Note: Set default options for this window in Family Module Preferences.


Patient Information

This information is specific to the patient.

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. See Drop Insurance Plan.

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 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 Ortho Auto Claims.

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:

Note:

  • 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.
    1. Click OK.
    2. Reopen the new plan.
    3. Double click to edit Benefit Information.

Warning: To make changes to an existing plan, see Change 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 security permission.

Audit Trail: View changes made to the insurance carrier, insurance plan, benefits, or employer. This audit trail is accessible to all users.

Pick From List: Select an existing insurance plan from the Insurance Plans list. Requires the Change existing Ins Plan using Pick List security permission. Alternately, drop the insurance plan before picking a new plan.

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.

Employer: Optional. Will also be added to the Employers.

Carrier: Required. Click [...] to pick an existing carrier from the Carriers 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/Payor ID: Provided by the insurance company if they accept E-Claims. Enter the ID manually or click Search ID to search the Payor ID list. If the carrier does not accept electronic claims, you have two choices.

Send Electronically: Determines whether e-claims can be sent electronically for this insurance plan. Defaults to the setting for the carrier (see Carriers) but can be changed by insurance plan..

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 Insurance Plan Types for more information.

Fee Schedule: The fee schedule used by this plan. If none, the provider's fee schedule is typically used. The only exception is if a fee schedule has been set on the Edit Patient Information window (e.g. a discount/cash fee schedule); this overrides other fee schedules.

Other Fee Schedules: See Types of Insurance Plans for more information.

Other Ins Info Tab

Use Alternate Code: Use alternate procedure codes when submitting claims (e.g. Medicaid). To associate alternate codes (Alt Code) with procedure codes, see Edit Procedure Code.

Substitution code options: These options determine whether or not estimated fees for procedures are downgraded based on substitution codes. Associate substitution codes to procedures in the Procedure Code List. Also see Estimate Downgrades.

Claims show UCR fee, not billed fee: Show the UCR fees of the treating provider on claims instead of the insurance fee. 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.

Claims show base units: Check this box to show base units on claims. Usually applies to medical insurance claims only. Base units are entered on the Edit Procedure Code window.

Claim Form: The form used for printed claims. Set the default in Claim Forms.

COB Rule: Select a Coordination of Benefits ( COB ) 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. See Insurance Filing Codes.

Filing Code Subtype: If the insurance filing code has a specific subtype, select it.

Billing Type: The plan's billing type. If the preference in Family Module Preferences for New patient primary insurance plan sets patient billing type is checked, and this is a new primary insurance plan, setting a billing type here will also assign the billing type to the patient on the Edit Patient Information window. (If you change an existing plan's billing type, it will not automatically change the patient's billing type).

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

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

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

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: 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 Security Permission Details, 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 security permission.

Request Electronic Benefits: If you have set up Electronic Eligibility and 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:

Benefits Last Verified: Indicates the date that insurance benefits were last marked verified (manually or using the Insurance 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.