Setting Up Carrier Coverage

After you have added a new insurance carrier, you can set up the amount of coverage the carrier pays for each procedure. Charges are attached to your procedure codes. The Insurance Coverage window enables you to enter the total amount the carrier pays and the amount for which the patient is responsible.

To enter carrier coverage:

Select Functions > Maintenance/Set-up > Carrier Maintenance from the menu bar.
In the OrthoTrac Carrier Lookup window, select the carrier and click Change. The Carrier Maintenance window is displayed.
Click Coverage. The Insurance Coverage window is displayed.
Click the Lock icon in the right corner of the window to set the status of this carrier to Locked or Unlocked.
The Lock icon controls whether changes made to your procedure codes apply to the selected carrier. If you edit your procedure codes and then make a global change, the changes do not apply to any carriers you have locked.

Select the Coverage Type for this carrier by clicking one of the option buttons.
- Variable — The carrier pays different percentages for different procedures; for example, 100% for records, 80% for exams, 50% for treatment.
- Fixed — The carrier pays the same percentage for all procedures; for example, 50%. If you select Fixed, enter the percentage amount, and the software assigns this amount to all procedures.
- If most of the procedure codes should be the same percentage, select Fixed and enter the percentage amount to automatically set the same percentage for all procedures. Then select Variable and change the codes that require a different percentage.
Select the first procedure code that you want to edit for this carrier and enter information in the columns.
- ADA — The ADA code assigned to this procedure.
- Fee — The doctor’s charge, posted to the responsible party’s ledger.
- Ins — The amount printed on the insurance claim, which is the maximum amount the carrier pays. This amount can never be more than the doctor’s fee.
- Coverage — The percentage of the charge the carrier actually pays. If you selected Fixed and entered a percentage, the Coverage column is automatically populated and cannot be changed.
After entering the amounts for all of the procedure codes, click OK.