Insurance Benefits

Insurance Benefits




Benefit Information

Benefit Information is found in the lower right of an Insurance Plan . 



The figures are used to calculate procedure and insurance remaining estimates. The details in the section apply to all subscribers of that particular insurance plan, so if you edit the benefits here, they change for all subscribers and their dependents. All Claim Procedures estimates will also change.

If subscribers have different benefits, create a different Plan instead of editing the current one.

Tracking Previously Used Benefits

If you need to make note of procedures completed outside your office for frequency limitation tracking or benefits available, you'll do this in the green Personal Information section of the Edit Insurance Plan window. See Insurance Plan for info.

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.

Edit Benefit Window

Only users with the "Insurance Plan Edit" Security permission can edit Benefit Information. To make edits, double-click anywhere in the Benefit Information grid. There are two ways to view the information: Simplified View and Row View.
  1. Simplified View: By default, the Simplified View checkbox will be marked on the upper left corner of the Edit Benefit window. Most practices prefer this view because information is organized by field and entering information is easier.
  2. Row View: If you don't use typical insurance categories, you can uncheck the Simplified View box and view the information in rows.

Enter 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. Details for each field are explored below.

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.

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.


Benefit Year

Practice-Web automatically resets benefits available for patients annually based on the renewal date selected.
  1. Calendar: Most plans run in a calendar year that runs from January through December, so you'll generally check this box.
  2. Month: If the plan starts any month other than January (plan year, benefit year, fiscal year, etc.), uncheck the "Calendar" box and enter the two-digit month in which benefits renew in the "Month" box. For example, February will be entered as "02" and December will be entered as "12."

Annual Max

Annual maximum, the yearly cap for insurance payments, may be entered for the individual or family. If the field is left blank, the system cannot perform Insurance Remaining Calculations. 

General Deductible

The deductible is the total amount the individual or family must pay before insurance will begin to pay. If the family deductible is met, either by a single family member or combined between family members, the system will not apply the individual deductible when calculating estimates. 

Fluoride Through Age

Many insurance companies set a maximum age for fluoride treatment. When an age is added here, estimates for fluoride codes, as determined in Treatment Plan Module Preferences, will consider the patient's age before applying benefits.

Sealants Through Age

Many insurance companies set a maximum age for sealants. When an age is added here, estimates for sealant codes, as determined in Treatment Plan Module Preferences, will consider the patient's age before applying benefits.

Frequencies

Bitewings, Panos or FMX, and exams are typically subject to frequency limitations, but the limitations will vary by plan. First, choose the appropriate timespan from the dropdown menu and then input the allowed numeral.
  1. Every # Years: Calculated using the Benefit Year selected at the top of the screen For example, a pano might be allowed every 5 years. If a patient had a pano in December 2025 and the plan rolls over in January, they'd be eligible for another pano in January 2030.
  2. # Per Benefit Year: Calculated using the Benefit Year entered at the top of the screen. For example, if it's 2 exams per benefit year and the plan rolls over in October, the patient could theoretically have two exams in October 2025, but then wouldn't be eligible for another exam until October 2026.
  3. Every # Months: Calculated based on rolling months. For example, if it's 1 exam every 6 months, and the patient has an exam in October 2025, they'd become eligible for another exam after April 2026. Some plans allow on the sixth month, while others stipulate six months plus one day or have other guidelines. Be mindful to confirm and mark accordingly!
  4. # in the Last 12 Months: Calculated based on the previous rolling 12 months. For example, if the limit is 1 exam in the last 12 months and the patient had an exam in October 2025, they'd be eligible after October 2026. Like the every "every # months" rolling period, plans may allow in the 12th month, at 12 months plus one day, or have similar guidelines. Be sure to mark accordingly.)

Individual Frequencies

If a patient's plan has different frequencies for some patients, such as those in high-risk groups or while pregnant, edit the frequency at an individual level. To do this:
  1. Open the Family Module and double-click on the Insurance Plan grid. The Edit Insurance Plan window will open.
  2. Double-click in the Benefit Information grid. The Edit Benefits window will open.
  3. In the Other Benefits grid, double-click the benefit you wish to edit or click "Add." The Edit Benefit window will open.
  4. Click the Patient Override box at the top, then edit the benefit as desired. Click "Ok" to save.


More

Pressing the "More" button below Frequencies brings up a variety of other common frequency limitations as seen below (diagnostic, preventative, restorative, periodontal, prosthodontics, implants). They are entered the same way as the main frequency section.


Ortho

If your practice offers orthodontic treatments and the plan offers ortho benefits, you'll enter them in this section.

Lifetime Max

By default, the Ortho code span runs from D8000 through D8999, so any procedures performed in this range will be tracked separately from the Annual Max as covered above and draw against the Ortho Lifetime Max listed here. General procedures are excluded from the Ortho Lifetime Max.

Percentage

This is where the category percentage goes for orthodontic treatment. For example, you might enter 50 to signify orthodontic procedures are covered at 50%. 

Ortho Through Age

Similar to fluoride and sealant benefits, some plans only cover orthodontic through a certain age. You'll enter the age limit here if one exists. 

Categories

Which category a procedure falls into is determined by the code span, which is accessible via Setup > Family/ Insurance  > Insurance Categories. The system comes set up with traditional code spans, though, so no global editing should be needed.

Preventative and Diagnostic Procedures

The first block shown includes preventative and diagnostic procedures. Enter a "Quick%" to change the percentage at which all procedures in the group are paid or, if procedures are covered at different percentages, enter each separately in the corresponding "%" box. Also make note of any individual or family deductibles. See the section on Individual and Family Amounts above for more details on how they work.

Basic Procedures

Procedures typically considered as basic needs are in the next category. These are listed as Restorative, Endo, Perio, and Oral Surgery. Again, a "Quick %" may be entered to change all percentages in this category at once or percentages may be added individually. If a waiting period applies, enter the number of months in the box which corresponds to the group. Bear in mind, an insurance company might say "basic has a 6-month wait." In which case, you'll typically want to enter "6" in all "# Months" boxes in this section.

Also note that insurance companies sometimes deviate from the norm and may classify code spans such as perio or oral surgery as major, so you'll need to account for those individually. 

Major Procedures

Procedures typically considered as major needs are in the final category. These are listed as Crowns and Prosthodontics. Again, a "Quick %" may be entered to change all percentages in this category at once or percentages may be added individually. If a waiting period applies, enter the number of months in the box which corresponds to the group. Bear in mind, an insurance company might say "major has a 12-month wait." In which case, you'll typically want to enter "12" in all "# Months" boxes in this section.

Other Benefits

The Other Benefits section will rarely be used, though can be used to override insurance percentages or amounts or for incentive plans. The benefits entered here are specific to the Insurance Plan you're viewing. 

Doubleclick a row to edit or click the Add button to add a new benefit. The following dialog will display.


Patient Override

Checking the Patient Override box impacts only this patient and this plan. You'll only check the box if it's an incentive plan and each family member is covered at a different percentage. 

Category or Proc Code

You can choose whether the benefit rule applies to an entire category of procedures or a single procedure code (proc code). Select the appropriate category or enter a single code. 

Type

Select what type of benefit rule you're adding.
  1. ActiveCoverage: This selection is informational only.
  2. CoInsurance: This selection impacts calculations for percentages, but not amounts.
  3. Deductible: This selection impacts calculations.
  4. CoPayment: This selection is informational only.
  5. Exclusions: This selection impacts calculations that use the exclusion settings in Family Module Preferences.
  6. Limitations: This setting impacts amount calculations but not percentages. 
  7. Waiting Period: This setting impacts calculations but the plan must have an effective date entered.

Percent

Enter the percent of coverage for the category or procedure code.

Amount

Enter the dollar amount insurance covers for the category or procedure code. 

Time Period

Choose the appropriate time period. Note that a selection of Service Year or Calendar Year will impact calculations but a selection of Lifetime or Years is informational only. 

Quantity/ Qualifier

If the category or procedure has a waiting period or frequency limitation, you'll enter the appropriate numeral in the quantity box and select a corresponding qualifier as follows:
  1. None
  2. Number of Services
  3. Age Limit
  4. Visits
  5. Years
  6. Months

Coverage Level

Use the Coverage Level to note whom the rule applies to. 
  1. Individual: The rule applies to each person covered by the plan. For example, the plan limits preventative coverage to $500 per year per person.
  2. Family: The rule applies to each family (as a whole) covered by the plan. This is more commonly used with categories. For example, a plan that limits preventative coverage to $500 per individual, but also stipulates the family's total preventative expenses for the year cannot exceed $1,000.
  3. None: The rule does not have a limit. For example, you're noting a percentage.

Notes

The "Notes" section displays for all patients on the Plan and shows in bold red in the insurance grid. 


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