Updating Benefit Tables

The Employer/Plan Benefit Table is the basis for calculating the estimated insurance benefit of each ADA code. You can break the ADA Code list into as many as 15 different numeric ranges and apply a different percentage to each range. You can also set up the deductible, maximum, and other information about the plan.

You can enter estimating details about specific ADA codes, so they can be properly estimated.

The code ranges are calculated based on office fees. Blue book updates do not affect these tables because those are code-specific updates.

To update the Benefit Table for an Employer/Plan, follow these steps:

From the Lists menu, select Employer/Plans. The Employer/Plan Pick List window is displayed.
Select the plan you want to edit, and click OK. The Employer/Plan Definition window is displayed.
Click Estimating. The Benefit Table window for that plan is displayed.
In the Individual deductible amount field, enter the amount of dental expense for which the patient is responsible. Click Annual or Lifetime.
In the Family deductible amount field, enter the deductible that is satisfied by combining expenses of all covered family members. For example, a program with a $25 deductible may have a family maximum of $75 for the family, regardless of the number of family members. Click Annual or Lifetime.
In the Individual maximum amount field, enter the maximum dollar amount per year that a dental program will pay toward the cost of dental service for each patient. Click Annual or Lifetime.
In the Ortho lifetime maximum amount, enter the lifetime benefit for orthodontic procedures.
In the Renewal field, enter the date the policy or plan renews.
Continue to add adjustment codes (for code-specific estimating) or transaction codes to the table, or click OK to save and exit.

Adding ADA Codes

In the fields on the left, you can enter ADA code ranges and the percentages at which they are paid by this plan. You can also select or deselect the Deductible Applies option for each category to indicate whether the patient’s deductible applies to the listed ADA codes. You can begin by copying the Office-wide Defaults.

Blue book updates override this table.

Adding Adjustment Codes

To add an adjustment code for automatic capitation or managed care write-off, follow these steps:

From the Lists menu, select Employer/Plans. The Employer/Plan Pick List window is displayed.
Select the plan you want to edit, and click OK. The Employer/Plan Definition window is displayed.
Click Estimating. The Benefit Table window for that plan is displayed.
Locate the Adjustment code to use for automatic capitation/managed care write-off section and click Select. The Transaction Code Pick List window is displayed with adjustment codes in the list.
Select the code you want to use and click OK. The code is displayed on the Benefit Table.

To add an adjustment code to use for automatic write-off of amounts in excess of UCR, follow these steps:

From the Lists menu, select Employer/Plans. The Employer/Plan Pick List window is displayed.
Select the plan you want to edit, and click OK. The Employer/Plan Definition window is displayed.
Click Estimating. The Benefit Table window for that plan is displayed.
Locate the Adjustment code to use for automatic write-off of amounts in excess of UCR section and click Select. The Transaction Code Pick List window is displayed with adjustment codes in the list.
Select the code you want to use and click OK. The code is displayed on the Benefit Table.
If you are uncertain about write-off amounts, do not select a UCR write-off code. Instead, enter your UCR write-off at the time you actually receive the insurance check.