Setting Up Insurance Plans > Adding Fee and Benefit Information
When setting up an Insurance Plan for Insurance Estimating, you must select an Estimation Method. (Tables > Insurance > Plans > Fees/Benefits)
The following methods are available:
Charge Amount = NOT USED
UCR = DMO allowable fee
Ext = Optional. This field is treated as a percentage when provided.
Insurance Percentage = NOT USED
Ins Share = 0
Pat Share = UCR
Writeoff = 0
When Ext is provided:
Ins Share = UCRxExt
Pat Share = UCR – Ins Share
Writeoff = 0
This calculation method replaces the office fee with the insurance UCR value.
If a percentage is NOT provided, the full amount is patient share and there is no insurance share and no writeoff. The UCR replaces the office fee at the ledger level.
If a percentage IS provided, then the insurance portion is the UCR multiplied by the percentage and the patient share is the difference between the UCR and the insurance share.
There is no write-off in this method.
Charge Amount = Office Fee
UCR = Insurance allowable fee
Ext = NOT USED
Insurance Percentage = NOT USED
Ins Share = UCR
Pat Share = Charge Amount – Ins Share
Writeoff = 0
In this method, the insurance specifies the exact dollar amount that it covers for each procedure.
The insurance share is this amount, and the patient share is the difference between the office fee and the insurance share.
There is no write-off in this method. The difference between the office fee and the UCR is paid by the patient.
Charge Amount = Office Fee
UCR = Insurance allowable fee
Ext = Percent of UCR that the insurance will pay
Insurance Percentage = NOT USED
Ins Share = UCRxExt
Pat Share = Charge Amount – Ins Share
Writeoff = 0
In this method, the insurance specifies the UCR amount, and also the percent amount that the insurance will pay.
The insurance share is the UCR multiplied by the percent coverage.
The patient share is the difference between the office fee and the insurance share.
There is no write-off in this method. The difference between the office fee and the UCR is paid by the patient.
Charge Amount = Office Fee
UCR = NOT USED
Ext = Optional. This field is treated as a percentage when provided
Insurance Percentage = Percent coverage based on procedure type
Ins Share = Charge Amount x Insurance Percentage
Pat Share = Charge Amount – Ins Share
Writeoff = 0
When Ext is provided:
Ins Share = Charge Amount x Ext
Pat Share = Charge Amount – Ins Share
Writeoff = 0
In this method, the insurance does not provide a UCR, but does provide percent coverage values, either by procedure category (ie, anesthesia, xray, or consult) or a procedure-specific percent.
If a procedure-specific percent is provided, this percent takes precedence over a category percent.
The insurance share is the office fee multiplied by the percent. The patient share is the difference between the office fee and the insurance share.
There is no write-off in this method.
Charge Amount = Office Fee
UCR = Insurance allowable fee
Ext = Optional. This field is treated as a flat dollar amount when provided
Insurance Percentage = NOT USED
Ins Share = UCR
Pat Share = 0
Writeoff = Charge Amount - UCR
When Ext is provided:
Ins Share = Ext
Pat Share = UCR – Ext
Writeoff = Charge Amount – UCR
In this method, the insurance provides a UCR fee. The insurance may also specify how much of the UCR fee will be paid.
If only a UCR is provided, the insurance share is the UCR, and the patient share is the difference between the office fee and the insurance share.
If an exact amount is provided in addition to the UCR, then the insurance share is this dollar amount, and the patient share is still the difference between the office fee and the insurance share.
The write-off amount is the difference between the office fee and the UCR.
Charge Amount = Office Fee
UCR = Insurance allowable fee
Ext = Optional. This field is treated as a percentage when provided
Insurance Percentage = Percent coverage based on procedure type
Ins Share = UCRxInsurance Percentage
Pat Share = UCR – Ins Share
Writeoff = Charge Amount - UCR
When Ext is provided:
Ins Share = UCRxExt
Pat Share = UCR – Ins Share
Writeoff = Charge Amount – UCR
In this method, the insurance specifies the UCR amount, as well as the percent amount that insurance will pay. This percentage may be a category percentage (ie, anesthesia, xray, or consults) or specific to the procedure.
If a procedure-specific percent is provided, this takes precedence over the category percent.
The insurance share is the UCR multiplied by the percent coverage. The patient share is the difference between the UCR and the insurance share.
The write-off is the difference between the office fee and the UCR.
Charge Amount = Office Fee
UCR = Insurance allowable fee
Ext = Required. This is a flat dollar amount.
Insurance Percentage = NOT USED
Ins Share = Ext
Pat Share = 0
Writeoff = Charge Amount – Ins Share
In this method, the insurance specifies the UCR amount and exact dollar amount per procedure that will be paid.
The insurance share is the exact dollar amount provided. The patient share is always $0 in this method.
The write-off is the difference between the office fee and the insurance share.
Charge Amount = Office Fee
UCR = Insurance allowable fee
Ext = Optional. This field is treated as a percentage when provided
Insurance Percentage = Percent coverage based on procedure type
Ins Share = UCRxInsPercent
Pat Share = 0
Writeoff = Charge Amount – Ins Share
If Ext field is provided:
Ins Share = UCRxExt
Pat Share = 0
Writeoff = Charge Amount – Ins Share
In this method, the insurance specifies the UCR amount, and the percent coverage, either by procedure category (ie, anesthesia, xray, or consult) or specific to a procedure.
If a procedure-specific percent is provided, this takes precedence over the category percent.
The insurance share is the UCR multiplied by the percent. The patient share is always $0 in this method.
The write-off is the difference between the office fee and the insurance share.