Examples of Other Benefits

Other Benefits for an insurance plan are useful for incentive plans or to override typical insurance percentages or amounts. Only specific scenarios are known to work and they are detailed below. There are no other known usages for other benefits. If you want to do something not listed below, it might not work. For example, setting up insurance substitution codes per insurance plan will not work. If you have another example that does work, please contact us.

See below for detailed setup of each known example:

In Simplified View, other benefits list as rows in the Other Benefits area of the Edit Benefits window. Click Add, or double click a row to edit.

For a detailed explanation of options on the Edit Benefit window, see Insurance Benefit Information - Row View.

Override a procedure or category benefit percentage for a specific patient but not everyone on the plan (e.g. incentive plans)

This may be necessary when you have an incentive plan and each family member is at a different percentage.

Cover a procedure at a different percentage, outside of the normal categories.

For example, nitrous oxide is covered at 50%, even though other procedures in that Insurance Category are not covered (0%).

Some work does not apply toward regular annual max

This may be necessary when you need to add a benefit that does not apply to the annual max. For each category you want to exclude from the annual max, create a new benefit. For the Amount, enter the annual limitation if there is one, or if no limit, enter a large amount (e.g. 99999).

Examples:

Each family member has a different annual maximum

For each family member, add an Other Benefit using the settings below.

Note: Remove the Annual Maximum values entered in the Edit Benefits window first. Otherwise, these annual maximum Other Benefits will not be applied.

You have different categories

Usually this means you are in a country other than the U.S. or Canada, and thus using Row View instead of Simplified View. Enter the insurance categories in Definition Setup and Insurance Categories. Then assign benefit amounts. For a Canadian Time Unit benefit example, see Canada Procedure Code Time Units.

No max for a category (e.g. preventive).

You can also set the time period as service year if appropriate. Test in the treatment plan module (e.g. add a $10000 preventive procedure and a $200 filling to make sure it behaves as expected.)

Set an age limitation (e.g. for sealants, fluoride)

The age limit is through the designated age. For example, entering 15 will cover the patient until their 16th birthday.