Insurance Plan

Insurance Plan



Every insurance plan has one subscriber and can be attached to multiple patients, but a plan is never shared between subscribers. There is no limit to the number of plans a family can have. If a patient changes their coverage, the old plan is not deleted, but stays on the list for future reference. 

Edit Insurance Plan Window (Overview)



Patient Information 


The Patient Information box at the top of the dialog is green by default, though can be changed by visiting Setup > Definitions > Misc Colors > Family Module Coverage.

This section may be blank if the Instance Plan is not attached to a patient.

Relationship to Subscriber

If the patient is the subscriber, this field will default to "self." Otherwise, you must select the appropriate relationship from the dropdown menu.

Optional Patient ID

The Optional Patient ID field is no longer used by most insurance companies. It can generally be left blank.

Drop

The Drop button is used when a patient no longer has the Insurance Plan specified. When you click it, you will automatically be returned to the Family Module. The plan will still appear in the Insurance Plans for Family dialog. It will not be deleted. 

Patient Plan ID

The Patient Plan ID is automatically generated by the system. It is sometimes used for third-party reporting.

Order

Order is used when a patient has multiple Plans and denotes the order in which the plans appear in the Family Module. The numeral can be changed at any time.
  1. 1 = Primary Insurance
  2. 2 = Secondary Insurance
  3. etc.

Eligibility Last Verified

As you verify insurance eligibility, either manually or through the Insurance Verification List, the date should be added to the Eligibility Last Verified field. Clicking the "Now" button automatically inserts the current date.

Pending

The Pending checkbox can be used for internal tracking and serves as a reminder that the patient's eligibility or benefits have not yet been confirmed.

Hist

The Hist button is used to edit  Insurance History . It's used for tracking procedures performed outside your office as they relate to frequency limitations, but may also be used to help track frequencies after a recent conversion to Practice-Web.

Ortho

If you're using Ortho Auto Claims, the Ortho button will allow you to see patient-specific information about the next claim the system will automatically generate.
  1. Next Claim Date: Displays the next date a Claim will be automatically created based on the date of the last automatically created claim and the established frequency/ Auto Proc Period.
  2. Fee: Displays the default fee as set on the Ortho Tab. If you'd like to override the fee for the next auto-generated claim, uncheck "Use Default Fee."

Adjustments to Insurance Benefits

Like Hist, Adjustments to Insurance Benefits is typically used to denote benefits used outside your office or if you've recently converted to Practice-Web.

Click "Add" to adjust the patient's benefits. T he amount automatically resets when the plan year rolls over.

Plan Info Tab



The left side of the Edit Insurance Plan window is divided into three tabs: Plan Info, Other Ins Info, and Ortho. Plan Info is the first tab and it displays general information about the patient's Insurance Plan. It can only be edited by users with the "Insurance Plan Edit" security permission.

Audit Trail

The Audit Trail button is available to all users. It allows team members to view changes made to the carrier, plan, benefits, or employer.

Pick From List

If the patient's plan is already entered in your system and appears on the Insurance Plans List, you may select it from the picklist here. This requires the " Change Existing Ins Plan Using Pick List" security permission.

Insurance Plan ID

The Insurance Plan ID is automatically generated by the system. It is sometimes used for third-party reporting.

Medical Insurance

If Medical Insurance is turned on at the practice level, the Medical Insurance checkbox will be visible and may be selected to denote medical insurance plans as opposed to dental plans.

Employer

The "Employer" field is optional. Before adding a new employer, click "Pick from List" to see if the employer is already in your system. When you select an existing employer group plan, the rest of the insurance fields will auto-populate. If the employer is not listed, you can add it and create the employer group plan.

Note, you may also change the employer name via the Employers List. It is a global change, so all people with that employer listed will see the change reflected.

Carrier

In the “Carrier” name field, enter the first few letters of the carrier. A drop-down list will open. If the desired carrier is on the list, then click on the carrier, the rest of the carrier information fields will auto-populate. If the desired carrier is not on the drop-down list, then continue to populate carrier information fields and the new carrier will be added to the “Carrier” list.

Note: Carrier information can be edited from the Carriers List. It's a global change, so all people with that carrier will see the change reflected.

Electronic ID/ Payor ID

If the insurance company/ carrier accepts electronic claims (e-claims/ eClaims), they can provide you with their Payor ID number. Click "Search ID" to search your Payor ID List. If it's not present, you can enter the ID manually. 

Note: If the insurance company does not accept electronic claims, you may:
  1. Leave the Electronic ID blank. Your clearinghouse will attempt to identify the correct Payor ID and send it electronically. If the carrier cannot be matched to a Payor ID, a paper claim will be sent by the clearinghouse. 
  2. Select "Don't send electronically" from the Send Electronically dropdown menu. Claims for the Insurance Plan will be marked as "paper" and you will need to print and mail them.


Send Electronically

The "Send Electronically" picklist determines whether claims can be electronically sent through your clearinghouse or whether you'll need to print and mail them. Your choice impacts the Insurance Plan globally. The carrier's setting is selected by default. You have three choices:
  1. Send Claims Electronically: Most Plans will have this setting. It allows for e-claims to be sent by your clearinghouse.
  2. Don't Send Claims Electronically: If you want to print and mail claims for the Plan, choose Don't Send Claims Electronically.
  3. Don't Send Secondary Claims Electronically: Secondary Plans typically require a copy of the primary EOB, so historically these needed to be printed and mailed and would therefore use this option. However, some clearinghouses now allow you to attach documents to the e-claim. 

Group Name

The "Group Name" is also optional.

Group Number

"Group Number" is mandatory. Populate this field with the correct group or policy number.

Other Subscribers

The first field indicates the total number of subscribers who use or have used the Plan. The dropdown menu beside it allows you to browse through the names of those subscribers.

Plan Type

The Plan Type indicates how the Plan pays. You can set the default option for new plans in Family Module Preferences.
  1. Category Percentage: Used to denote Plans that pay a certain percentage of each procedure or procedure type, such as 100% on preventative, 80% on basic, 50% on major. Category percentage plans can be used with or without Fee Schedules. However, in most cases, you’ll want to leave the “Fee Schedule” dropdown menu set to “none,” so that the provider’s fees are charged. If you know what fees the plan pays for each procedure, you’ll enter them as an Out of Network Fee Schedule and then select the corresponding Fee Schedule from the Carrier Allowed Amounts dropdown in the Edit Insurance Plan window. That way, the system knows the plan is only going to pay a percentage of the allowed fees and assigns any differences between the provider’s fees and allowed amount to the patient when creating estimates.
  2. PPO Percentage: Short for Preferred Provider Organizations, a PPO Percentage Plan works similarly to a category percentage, but you should use a Fee Schedule to denote your contracted amounts for each procedure. This way, your estimates show the anticipated write-off amount. Plus, it’s easier to track write-offs, production, and other essential metrics.
  3. PPO Fixed Benefit:  You’ll only use the PPO Fixed Benefit option if you’re in-network for the carrier and they pay a set amount for each procedure rather than a percentage. This way, the write-offs will be automatically calculated and tracked for you.
  4. Medicaid or Flat Co-pay:  When the Medicaid or Flat Co-Pay Plan Type is selected, the system will automatically calculate that all procedures have 100% coverage with no maximum or deductible. You will not be able to change any of the percentage amounts and write-offs are not tracked.
  5. Capitation:  Used with HMO and DMO plans, in which the patient typically pays a discounted rate for procedures, selection of the Capitation Plan Type will disable all percentages. The system will also track any write-offs.

Fee Schedule




You’ll usually only be selecting a Fee Schedule Type when you create a new Fee Schedule or Plan, though you may need to edit one if it has been entered incorrectly previously.  If the plan does not use a special Fee Schedule, the practice UCR fees are typically used.

There are four Fee Schedule Types in Practice-Web.  
  1. Normal:   If you’re contracted with PPO plans (in-network), you’ll select “Normal” when creating new a Fee Schedule for these plans.
  2. CoPay:  A CoPay Fee Schedule is used when the patient is responsible for paying a certain dollar amount for each procedure. This would be the case with HMO plans, in which the patient usually pays a reduced fee for services, but you might also see it alongside some percentage plans too. It’s also worth noting that, if a plan has a co-pay charged for the visit, rather than for each procedure, or in addition to procedures, you’ll want to set up a new non-D procedure code to account for the charge and add the procedure code to each appointment.
    Note: A blank entry in Copay Fee Schedules may be treated as the patient co-pay being $0 or the patient having a 100% co-pay depending on your Family Module Preferences. To check or change your settings, go to “Setup” in the main menu, select “Family/ Insurance,” and then “Family Preferences.”
  3. Out of Network:  It’s helpful to input allowed amounts of plans you’re not contracted with to ensure you’re providing patients with more accurate estimates. Although the difference won’t show as a write-off, the system will recognize the insurance company is only going to pay a percentage of the amount you’ve entered for any given procedure. For this reason, you’ll only want to enter a zero for any given procedure if you know the carrier is not going to pay anything at all. Otherwise, leave it blank and the system will use the provider’s fees.
  4. FixedBenefit:   If you’re contracted with an insurance company and the PPO plan pays a set amount for each procedure rather than a percentage, you’ll use the FixedBenefit Fee Schedule Type. A blank entry may be treated as the patient portion being $0 or the patient being responsible for the full PPO contracted amount depending on your Family Module Preferences.
  5. None:  Fee Schedule dropdown menu says “none,” to denote that no Fee Schedule has been selected for that plan, the system will use the provider’s fee schedule by default.

Patient Co-pay Amts

"Patient Co-pay Amts (Cap only)" will always be "NONE" unless this is a Capitation Plan. For information on how to set up capitation plans, please read the chapter on Setup Medicaid/Capitation.

Carrier Allowed Amounts

The Carrier Allowed Amount is used for out-of-network fee schedules.

Other Ins Info Tab



The Other Ins Info tab hosts additional information about the plan that rarely needs to be adjusted. 

Subst Codes

Many insurance plans use substitute codes of common procedures, such as PFMs and posterior composite fillings. This may also be referred to as downcoding or downgrading.  When you press the "Subst Codes" button, the following dialog will appear:


From the Insurance Plan Substitutution Codes window, you can adjust which codes are downgraded by the Plan and which codes are used in their place. 

Doublecheck that the box next to "Don't Substitute Codes" is unchecked, so any substitution codes you've entered work properly.

Use Alternate Code

Some Plans, such as Medicaid plans may require the use of an alternate code ("Alt Code") on claims. To associate an Alt Code with a Procedure, edit it via the Procedure Code List. Then, check the box here.

Don't Substitute Codes

Leave the "Don't Substitute Codes" box unchecked to ensure commonly downgraded codes are calculated properly on estimates. Common downgrades are in the system by default, though you can add or edit these by clicking the Subst Codes button.

If you check the box, any substitution codes entered will be ignored when creating estimates and the system will assume the Plan is paying based on the actual Procedure Code billed.

PPO Substitution Calculate Writeoffs

When checked, this box indicates a write-off between the office fee and the originally charted fee for substituted codes will be calculated on estimates. If unchecked, no write-off will be calculated.

Claims Show UCR Fee, Not Billed Fee

When this box is checked, the treating provider's UCR fees will be used on claims rather than the insurance fees. The default setting for new plans can be changed in Family Module Preferences.

Hidden

If you don't want a Plan to be able to be viewed on the Insurance Plan List or copied and used for other subscribers, you may hide it. If the Plan already has multiple subscribers and you want to hide it for everyone, you'll also need to select the "Change Plan for all subscribers" radio button at the bottom of the Edit Insurance Plan window.

Claims Show Base Units

Base units are usually only used with medical claims. Check the box next to "Claims Show Base Units" to include the field on claims. To add Base Units for individual Procedures, you will need to go to edit the Procedure Code by choosing Lists from the main menu, then Procedure Codes, and then selecting the code you wish to edit.

Claim Form

"Claim Form" will typically be ADA 2019. You can change the default by choosing Setup in the main menu, then Family/Insurance, then Claim Forms.

COB

The COB picklist allows you to determine the coordination of benefits. The default setting may be changed in Family Module Preferences.

Filing Code

The default Filing Code for e-claims is "Commercial Insurance." If the Filing Code is incorrect, the carrier will reject claims. Confirm with the insurance carrier before changing this setting.

Filing Code Subtype

If the carrier provides you with a Filing Code Subtype, you may select it here.

Billing Type

Family Module Preferences determine the behavior of the Billing Type. If the box for "New patient primary insurance plan sets billing type" is checked, setting a Billing Type for a new patient will assign the same Billing Type in the Edit Patient Information dialog. 

Exclusion Fee Rule

The Exclusion Fee Rule applies only to PPO Plan Types. Exclusions are defined by setting coverage to 0% using Other Benefits. You have three choices:
  1. Practice Default: Set via Family Module Preferences
  2. Do Nothing: Any exclusions will be billed at the Plan Fee Schedule.
  3. Use UCR Fee: Any exclusions will be billed at the UCR fee rather than your in-network contracted rate.

Ortho Tab



If your practice offers orthodontic treatment, you will want to ensure orthodontic claims are handled according to your practice guidelines too. 

Ortho Claim Type

The Ortho Claim Type is used to denote how the carrier wants to receive orthodontic claims. There are three options.
  1. Initial Claim Only: Indicates the carrier only wants a single claim for the initial procedure.
  2. Initial Plus Visit: Indicates the carrier wants a claim for the initial visit and additional claims for each subsequent visit.
  3. Initial Plus Periodic: Indicates the carrier wants a claim for the initial procedure and then periodically for a certain fee and procedure. If this option is selected, claims may be automatically generated using the Auto Ortho Tool and the following fields will become editable: 
    1. Ortho Auto Proc: This field determines which code will be included on automatically-generated claims. The default for new Plans can be changed in Ortho Setup or the code for this Plan can be changed individually by clicking the ellipsis button [...].
    2. Ortho Auto Fee: This field determines the fee that will be automatically billed for the procedure on the auto-claim.
    3. Auto Proc Period: The Auto Proc Field determines how often claims are automatically generated (monthly, quarterly, semi-annually, or annually).
    4. Wait 30 days before creating the first automatic claim. This box should be checked if the carrier requires you to wait 30 days after the patient's initial visit before sending periodic claims. If this box is checked,the Auto Ortho Claim list will show the claim 30 days after the initial procedure date.

Plan Note

Any information entered in the Plan Note field will display for all patients on the Plan and will appear in the insurance grid in bold red. This should not be confused with the "Note" field that appears under Subscriber Information, which only displays for that Subscriber and dependents.

Label

The label button can be used to automatically print the insurance carrier's mailing address on a mailing label.

Delete

If the patient you're viewing is the only patient on the plan and the subscriber, clicking "Delete" will delete the plan and remove it from the Insurance Plan List. If there are additional subscribers associated with the Plan, the delete button will only remove the plan for this subscriber and their dependents. 

Create a New Plan if Needed/ Change Plan for All Subscribers


Change Plan:  This is  the default setting but can be changed in Family Module Preferences. Generally speaking, it's best to select the radio button for "Change Plan for all Subscribers," as this will edit the Plan globally for all subscribers and patients using it, which is helpful if the Plan information you have is outdated, inaccurate, or incomplete. Most changes made this way do not impact claims or historical estimates. You can also change plan information for all subscribers by going to the Insurance Plans List and choosing the appropriate Plan

Create New Plan: I f "Create new Plan if needed" is selected, certain changes to the plan will trigger the creation of a new plan for this Subscriber only. Although it may be necessary at times, practices that use this setting typically wind up with multiple copies of Plans that need to be maintained and updated.

Subscriber Information



Subscriber information can be found in the top right corner of the Edit Insurance Plan window. The Subscriber is automatically set when the Insurance Plan is created. If there are no outstanding claims associated with this Subscriber, you may change the Subscriber by clicking the "Change" button.

Subscriber ID

The Subscriber ID cannot be blank and is usually the SSN from the Edit Patient Information window in the "Other" tab, but it can be manually changed to an alternate ID supplied by the carrier too. If billing Medicaid, use the Medicaid ID number and fill in the Medicaid ID field in the Edit Patient Information window too.

Effective Dates

Effective Dates are used when the Plan has a waiting period before benefits are applied. Adding a termination date in the future will not automatically remove or end the Plan for a patient on that date. You will need to Drop the plan manually.

Release of Information

If the patient signed a contract that indicates you have permission to share protected health information with the insurance company to carry out payment-related activities, check this box. Box 36 of the claim form will display the phrase "Signature on File."

Assignment of Benefits

This box must be checked in order for payments to be sent from the insurance company to the provider. If left unchecked, the patient will receive the payment. 

Notes

The "Note" field that appears under Subscriber Information only displays the information added for that Subscriber and dependents and in the insurance grid in bold red. It should not be confused with the  Plan Note field, which will display for all patients on the Plan.

Benefits




Only users with the "Insurance Plan Edit" Security permission can edit Benefit Information. 



Request Electronic Benefits

If you're using an electronic claims clearinghouse and are signed up to receive Electronic Eligibility and Benefits, getting insurance data is as easy as ensuring a Subscriber ID is entered and clicking "Request." You can also view the history of requests by clicking "History."

Import Benefits

Practices using the Trojan Bridge can import a copy of Trojan data as well. Be advised that "Notes" are typically "read only," so you will need to manually read them and respond accordingly. 

Benefits Last Verified

This field indicates when insurance benefits were last marked verified using the Insurance Verification List or manually. Clicking "Now" automatically enters the current date.

Don't Verify

Checking the box next to "Don't Verify" excludes this Plan from the Insurance Plan Verification List.

Benefit Information

To enter Annual Max Benefits, Deductible, and Benefit Percentages double-click in the Benefit Information area.


The following dialog will open.


Enter all your amounts in the boxes at the top. When finished, click on the “OK” button in the lower right of the “Edit Benefits” dialog.

Keep in mind that leaving a box blank is not the same as entering a zero. Blank indicates that the amount is unknown. If you leave the Annual Max blank, then no calculations can be done to indicate how much is remaining benefits are left.

The Calendar Year checkbox at the top applies to most of the benefits. The checkbox at the bottom is only used for the Other Benefits list.

Individual and Family Amounts

At the top, there are boxes for Individual amounts and boxes for Family amounts. 

If Individual amounts are to be used, then leave the Family amounts blank.


If Family amounts are to be used, then leave the Individual amounts blank.



Add Insurance Plan to Subscriber 

From the Family module, click on the "Add Insurance" button. The following dialog opens.


If the patient is the subscriber, click on the "Yes" button. The "Edit Insurance Plan" dialog will open. Complete the fields as indicated above.

Change Current Insurance Plan to New Insurance Plan for Subscriber 

From within the Family Module, double-click on the right side of the "Primary Insurance Plan" area.  The "Edit Primary Insurance Plan" dialog will open.


In the upper left, click on the "Drop" button.  This will return you to the Family module.

Click on the "Add Insurance" button. The following dialog will open.


Click on the "Yes" button.  The following dialog will open.


Click on the "New Plan" button.  The "Edit Insurance Plan" dialog will open.
Follow instructions for completing the Edit Insurance Plan window as shown above.

Edit Current Insurance Coverage 

NOTE: DO NOT change the name of the insurance company, to change the insurance plan to another insurance company. Use the DROP button instead.
From within the Family Module, double left click on the right side of the "Primary Insurance Plan" area.
The "Edit Primary Insurance Plan" dialog will open.

Edit the fields as needed. When finished, click on the "OK" button in the lower right of the "Edit Insurance Plan".

Assign Existing Insurance Plan to a Dependant 

After the dependent has been added to the guarantor's family account, click on the "Add Insurance" button.  The following dialog will open.


Click the "No" button. The following dialog will open.


Highlight the subscriber and click on the "OK" button.  The following dialog will open.


Highlight the insurance plan and click on the "OK" button.  The "Edit Insurance Plan" dialog will open.

In the upper left (Green Area) in the "Relationship to Subscriber", click on the down arrow button and select the correct relationship. Then click on the "OK" button.


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