Setting Up Insurance > Handling Insurance Plan Information

Adding Insurance Plans

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• Enter insurance company information before associating insurance plans.

• When making an appointment or posting transactions, the patient insurance effective date and the plan’s limitations are used to dictate whether the patient is covered for a procedure.

• Before associating an insurance plan with an employer, enter the employer information. For more information, see Handling Employer Information.

• You cannot change the plan type after saving the record.

You can add percentage, flat fee, preferred provider, DMO/Capitation, Medicare, and Medicaid plans.

To add an insurance plan:

1. Select List > Ins. Plan. The Insurance Plan List window is displayed.

2. Press Enter. The name of the insurance company is displayed in the title bar.

3. Click Add. The Insurance Plan window is displayed. The identification number for the new insurance plan is displayed next to the Plan ID field.

4. If you subscribe to Trojan, select a Trojan carrier identification number from the Trojan ID drop-down list.

5. Type the insurance plan name.

6. Select the insurance company that sends payments from the Insurance Co drop-down list, select the insurance company office to send claims to from the Mail To drop-down list, and if the insurance plan is associated with only one employer, select it from the Default Employer drop-down list.

7. Type any phone numbers and notes.

8. Press Alt + Enter to move the cursor to the Information tab, and type the plan's group number in the Group Number field.

9. Select an option from the Plan Type drop-down list:

• To enter a dental plan:To enter a dental plan:Select Dental.

• To enter a medical plan:To enter a medical plan:Select Medical. The Maximum Coverage, Family Deductible, Orthodontics Maximum, and Individual Deductible fields are disabled for medical insurance plans.

10. Select the estimation type from the Estimation Type drop-down list:

11. If the insurance plan uses a flat fee rate:If the insurance plan uses a flat fee rate:Select Flat Fee.

12. If the insurance plan pays a percentage of procedural costs:If the insurance plan pays a percentage of procedural costs:Select Percentage.

13. If the insurance plan pays a percentage of the procedural costs based upon your allowed amounts:If the insurance plan pays a percentage of the procedural costs based upon your allowed amounts:Select % PPO.

14. If the insurance plan pays a flat fee for procedural costs:If the insurance plan pays a flat fee for procedural costs:Select Flat Fee PPO.

15. If the insurance plan negotiates a reimbursement amount for procedural costs:If the insurance plan negotiates a reimbursement amount for procedural costs:Select DMO/Capitation.

16. If the insurance plan pays a flat fee for procedural costs based upon the Medicare plan’s allowed amounts:If the insurance plan pays a flat fee for procedural costs based upon the Medicare plan’s allowed amounts:Select Flat Medicare.

17. If the insurance plan pays a percentage of the procedural costs based upon the Medicare plan’s allowed amounts:If the insurance plan pays a percentage of the procedural costs based upon the Medicare plan’s allowed amounts:Select % Medicare.

18. If the insurance plan negotiates a reimbursement amount for procedural amounts for patients on medical assistance or welfare:If the insurance plan negotiates a reimbursement amount for procedural amounts for patients on medical assistance or welfare:Select Medicaid.

11. Select the month within which the plan’s deductible and year-to-date benefits are reset from the Anniversary Month drop-down calendar. If the plan has a lifetime deductible, select None/Other.

12. Select an option:

13. After the maximum coverage amount is reached, the estimated insurance amount is 0. Treatment plan procedures affect this amount after they are completed and posted.

• If the insurance plan has a yearly maximum:If the insurance plan has a yearly maximum:Select Maximum Coverage and select the amount from the calculator.

• If the insurance plan has an orthodontics maximum:If the insurance plan has an orthodontics maximum:Select the amount from the Orthodontics Maximum calculator.

• If the insurance plan has a family deductible:If the insurance plan has a family deductible:Select the amount from the Family Deductible calculator. The family deductible amount must be greater than or equal to the individual deductible amount.

• If the insurance plan has an individual deductible:If the insurance plan has an individual deductible:Select it from the Individual Deductible calculator.

• If you are entering a DMO/Capitation or Medicaid plan:If you are entering a DMO/Capitation or Medicaid plan:Select the amount charged per patient visit from the Charge Per Visit calculator.

13. Click OK.

14. If you are entering a dental or medical flat Medicare, percentage Medicare, percentage PPO, or flat fee PPO estimation type and want to post the write-off at the time of service, select Post Write Off at time of service.

• If this option is not selected, the write-off is calculated in Write Off mode when posting a bulk insurance payment.

15. If you are entering a dental or medical flat Medicare, percentage Medicare, percentage PPO, or flat fee PPO estimation type and the plan requires an additional risk and development write-off, type the percentage in the Risk Writeoff % field. This amount is automatically calculated when an insurance payment is posted.

16. These fields are not enabled for percentage, flat fee, DMO/Capitation, and Medicaid insurance plans.

16. Click the Coverage tab or press Ctrl + Tab and enter insurance coverage information for each procedure class on this tab. This information is used to estimate the patient and insurance portions of fees. Dental and medical procedures are classified differently.

17. Select an option:

18. If you are entering a medical percentage, PPO percentage, flat fee, flat fee PPO, flat medicare, or flat Medicare percentage:If you are entering a medical percentage, PPO percentage, flat fee, flat fee PPO, flat medicare, or flat Medicare percentage:Type the coverage percentage amount.

19. If you are entering a dental percentage, flat fee, PPO percentage, flat fee PPO, flat Medicare percentage, or Medicare percentage insurance plan and deductibles apply for the procedural group:If you are entering a dental percentage, flat fee, PPO percentage, flat fee PPO, flat Medicare percentage, or Medicare percentage insurance plan and deductibles apply for the procedural group:Type the coverage percentage and select Ded.

20. If you are entering a dental or medical DMO/Capitation or Medicaid plan and the procedural class is covered:If you are entering a dental or medical DMO/Capitation or Medicaid plan and the procedural class is covered:Select Cov’d and type the class copay in the Copay field.

18. If there is a waiting period before which the procedure is not covered, select Wait Pd and type the number of months in the Mos field.

19. Click the Claim Filing tab or press Ctrl + Tab. Claim form and eClaims information is displayed on the tab.

20. Select an option:

• Some insurance plans, such as capitation plans, do not require printed claims; in that case, the message is displayed, asking you to delete the claim.

18. To print a claim each time you submit a transaction for a patient covered on the plan:To print a claim each time you submit a transaction for a patient covered on the plan:Select Print Claim Form # and type the claim number in the field.

19. To scale the copyright information to print on one page:To scale the copyright information to print on one page:Select Scale To Fit.

20. To print an alternative insurance code instead of the procedure code on Medicaid claim forms:To print an alternative insurance code instead of the procedure code on Medicaid claim forms:Select Use Alternate Display.

21. To submit diagnosis codes with dental codes:To submit diagnosis codes with dental codes:Select Use Diagnosis Codes. When this option is selected, the Diagnosis Codes fields in the Transactions window are displayed even when you enter a dental procedural code.

• The ADA form #17, ADA form #58, ADA form #77, HCFA form #34, HCFA form #35, HCFA form #36, and HCFA form #37 accommodate diagnosis codes.

• To print an alphabetical character before the transaction code to indicate a specific Medicaid message:To print an alphabetical character before the transaction code to indicate a specific Medicaid message:Select Use HCPCS Codes. This field is enabled for medical insurance plans.

• If the insurance company requires approval of procedures before they are performed:If the insurance company requires approval of procedures before they are performed:Select Preauthorization Required.

• If the account guarantor’s employee number is required instead of the Social Security number on the claim:If the account guarantor’s employee number is required instead of the Social Security number on the claim:Select Use Guarantor Employee #.

• If Use Guarantor Employee # is selected and no employee ID is in the account record, the Social Security number is printed on claims.

• To send the insurance reimbursement to the patient instead of your office:To send the insurance reimbursement to the patient instead of your office:Select Benefits To Patient. You are prompted to delete insurance plan claims after they are submitted.

• If a signature on file is accepted in lieu of the patient’s signature on insurance plan claims:If a signature on file is accepted in lieu of the patient’s signature on insurance plan claims:Select Accept Signature On File.

• To subtract deductibles before applying the percentages when calculating the insurance payment:To subtract deductibles before applying the percentages when calculating the insurance payment:Select Subtract Deductible First. This setting applies only to percentage plans and flat fee plans without bluebook entries.

• To prefix all CDT codes with the letter D:To prefix all CDT codes with the letter D:Select Proceed CDT Codes with the letter ’D’ and type the CDT format version in the This plan accepts CDT Version field.

• To enable CDT code formatting for all insurance plans, select System > Fees Maintenance > Enable CDT Code Formatting.

• If you subscribe to eClaims:If you subscribe to eClaims:Select a plan from the ECS Plan Type drop-down list.

• If the plan belongs to an insurance company that accepts electronic primary dental insurance claim filing:If the plan belongs to an insurance company that accepts electronic primary dental insurance claim filing:Select ECS Capable Primary.

• Primary and secondary options are enabled only if a payer identification number is included in the insurance company record.

21. If the plan belongs to an insurance company that accepts electronic primary dental insurance claim filing for secondary claims:If the plan belongs to an insurance company that accepts electronic primary dental insurance claim filing for secondary claims:Select ECS Capable Secondary.

22. If the plan accepts electronic treatment plan preauthorization claims:If the plan accepts electronic treatment plan preauthorization claims:Select ECS Preauth.

23. If the plan provides coverage for ortho procedures and requires claim resubmission:If the plan provides coverage for ortho procedures and requires claim resubmission:Select Resubmit Ortho Ins Form.

24. If the plan provides coverage for ortho procedures and requires coupon resubmission or continuous care forms:If the plan provides coverage for ortho procedures and requires coupon resubmission or continuous care forms:Select Resubmit Continuous Care Form and type the resubmission frequency in the Payment/Resubmission Frequency field.

25. To treat the patient as the guarantor of claims associated with the insurance plan:To treat the patient as the guarantor of claims associated with the insurance plan:Select Treat Patient as Guarantor for Claim.

26. To estimate the secondary insurance amount based on the total fee minus the deductible, minus the amount already estimated to be paid by the primary plan:To estimate the secondary insurance amount based on the total fee minus the deductible, minus the amount already estimated to be paid by the primary plan:Select Coordinate benefits when used as secondary plan.
    
    Note:  If this option is not selected, the software estimates the secondary amount using the total fee and does not take into account the amount already estimated to be paid by the primary plan.

27. To print discount transactions on the claim form:To print discount transactions on the claim form:Select Print discount transactions on claim.
    
    Note: Use this option if an insurance company requests that discounts posted to a patient's ledger be printed on the claim form (for example, a discount to waive the patient's copay).

28. To specify whether a plan accepts Signature On File for the Billing and Treating Drs signature areas on a claim form:To specify whether a plan accepts Signature On File for the Billing and Treating Drs signature areas on a claim form:Select Accept Dr. Signature On File.

21. Click the Contact Info tab or press Ctrl + Tab.

22. Type additional phone numbers and e-mail addresses.

23. Click OK.

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Related Topics

Setting Up Insurance Plans