Code-Specific Estimating

Use the Benefit Details window to set up details for capitation and other managed care plans, such as HMOs and PPOs. For each ADA code, select a patient payment method, and insurance payment method, and other code-specific details.

Most of the ADA codes in a fee-for-service plan are covered by the table of code ranges and the related percentage benefit, but there are frequently exceptions for individual ADA codes. Enter these details into the system for the most accurate insurance estimation.

This is the first information PracticeWorks checks when estimating the cost of a procedure. Estimating set at this level applies to all patients with this particular Employer/Plan. If no information is set here, the software checks the Employer/Plan benefit table.

To enter code-specific estimating information for an Employer/Plan:

In the Benefit Table window, click Code-specific estimating. The Benefit Details window is displayed.
Select a code.
Under Patient payment method, select the option that applies to the Employer/Plan. If you select Patient pays fixed amount, you must enter the amount as well.

If the Patient payment method is changed from Option 1, you must assign a write-off code on the previous (Benefit Table) window, so that the write off is displayed on the Checkout Ledger and Tx Plan windows.

Under Insurance payment method, select the applicable method, and enter the percentage or amount as required.
(Percentage for a PPO plan, Fixed for an HMO/DMO plan, Not covered or cap for a procedure insurance does not cover.)
Under Other insurance information, select the deductible option that applies to the Employer/Plan, and type the Maximum fee considered (UCR) and the Insurance payment frequency (mo.) as required.
Repeat steps 2 through 5 as needed for additional codes.
Click OK.

Code-Specific Estimating Examples

Scenario 1

The insurance company pays a fixed amount and the patient is to pay a fixed amount. (Typically an HMO/DMO plan, but this scenario might apply if the insurance company downgrades procedures.) Any difference between the regular fee and the insurance company's fixed amount must be written off.

Under Patient payment method, selectselect Option 3: Patient pays fixed amount; office writes off any balance not paid by insurance. Enter amount.

Under Insurance payment method, selectselect Fixed amount: Enter amount.

Scenario 2

The insurance company pays a fixed amount and the patient is to pay the remaining amount.

Under Patient payment method, selectselect Option 1: Patient pays whatever insurance doesn't pay, including any amount in excess of UCR.

Under Insurance payment method, selectselect Fixed amount: Enter amount.

Under Other insurance information, selectselect Deductible applies.

The Deductible applies option varies with each ADA code.

Scenario 3

The insurance company does not cover a procedure, and the office is not allowed to collect a fee from the patient.

Under Patient payment method, selectselect Option 4: Patient pays ONLY any applicable deductible; office writes off any balance not paid by insurance (Capitation - type plan).

Under Insurance payment method, selectselect Only covered by capitation plan, or insurance does not cover at all.

Scenario 4

The insurance company does not cover a procedure and the patient is responsible for the full fee.

Under Patient payment method, selectselect Option 1: Patient pays whatever insurance doesn't pay, including any amount in excess of UCR.

Under Insurance payment method, selectselect Only covered by capitation plan, or insurance does not cover at all.

Scenario 5

The insurance company pays a percentage of their scheduled amount. If there is a difference between your regular fee and the insurance company scheduled amount, it must be written off by the office.

Under Patient payment method, selectselect Option 2: Patient pays any part of the UCR fee not covered by insurance. Office writes off any fees in excess of UCR.

Under Insurance payment method, selectselect Percentage: Enter the percentage and UCR, and choose whether or not the deductible applies.

Helpful Hints:Helpful Hints:

When using the Maximum fee considered (UCR) field, keep the following in mind:

The UCR amount must be less than or equal to your regular fee charged, in order to calculate correctly.
It might be necessary to have both write-off adjustment codes selected in a single employer plan on the Benefit Table window.
In order to correctly calculate the write-off by producer, the Write-off by producer option must be selected under File > Preferences.