Adding exceptions in coverage table templates

You can add exceptions to the percentage covered by insurance for a procedure or range of procedures in any of the coverage table templates.

Tip: You can add exceptions in a coverage table that is attached to an insurance plan.

Note: The exceptions in coverage tables are used by Dentrix Ascend to automatically calculate insurance estimates. If a patient has dual coverage, the exceptions of the primary insurance coverage are used. Also, a posted procedure with an exception will have a warning icon next to it in the following areas of Dentrix Ascend: in the Enter payment dialog box, in the Enter credit adjustment dialog box, on the Payment tab of the Patient Walkout dialog box, and on the treatment plan case preview page. You can click a warning icon to view the details of the exception for the corresponding procedure.

To add an exception

  1. On the Settings menu, under Production, click (or tap) Coverage Tables.

    The Coverage Table Setup page opens.

  2. Select a coverage table template.

    The options for editing the coverage table appear.

    Insurance Coverage, %

    Patient Copayment, $

  3. Click (or tap) Manage Exceptions.

    The Manage Exceptions dialog box appears.

  4. Click (or tap) Add New Exception.

    The New Exception for Procedure(s) dialog box appears.

  5. Set up the options on the following tabs as needed:

    • Exception Type

      1. Select one of the following options:

        • Not covered - To add procedures that are not covered.

        • Frequency - To add procedures that are covered at certain intervals.

        • Downgrade - To add a procedure that requires a downgrade.

        • Age limitation - To add procedures that have an age limitation.

      2. Click (or tap) Next.

    • Select Procedure(s)

      1. Do one of the following:

        • For a "Not covered" exception type, select the checkboxes that correspond to the procedure codes that are not covered.

          Notes:

          • Only the procedure codes that do not have any exceptions are available for selection.

          • To quickly select or clear all checkboxes, select or clear the checkbox in the header at the top of the list.

          • To quickly select or clear a range of checkboxes, click (or tap) the first checkbox of the desired range, and then, while pressing the Shift key, click (or tap) the last checkbox of the desired range.

        • For a "Frequency" exception type, select the checkboxes that correspond to the procedure codes that are covered at certain intervals.

          Notes:

          • Only the procedure codes that do not have a "Not covered" or "Frequency" exception are available for selection.

          • To quickly select or clear all checkboxes, select or clear the checkbox in the header at the top of the list.

          • To quickly select or clear a range of checkboxes, click (or tap) the first checkbox of the desired range, and then, while pressing the Shift key, click (or tap) the last checkbox of the desired range.

        • For a "Downgrade" exception type, select the procedure code that requires a downgrade.

          Note: Only the procedure codes that do not have a "Not covered" or "Downgrade" exception are available for selection.

        • For an "Age limitation" exception type, select the checkboxes that correspond to the procedure codes that have an age limitation.

          Notes:

          • Only the procedure codes that do not have a "Not covered" or "Age limitation" exception are available for selection.

          • To quickly select or clear all checkboxes, select or clear the checkbox in the header at the top of the list.

          • To quickly select or clear a range of checkboxes, click (or tap) the first checkbox of the desired range, and then, while pressing the Shift key, click (or tap) the last checkbox of the desired range.

        Notes:

        • To search for a procedure, begin entering the code or its description in the Search for procedure box, continue typing as needed to narrow down the procedure code list.

        • After searching for and selecting a procedure, to return to viewing the entire procedure code list, delete the search text from the Search for procedure box.

      2. Click (or tap) Next.

    • Specify Options

      1. Do one of the following:

        • For a "Not covered" exception type, there are no options on this tab.

        • For a "Frequency" exception type, specify how often the insurance carrier covers this procedure within a given time period. For How many times, either enter a number, or click (or tap) + or - to change the number. For Over the course of, enter a number, and then select Year(s), Month(s), or Day(s) from the list.

          Note: Because the frequency exception works only by code, the procedure code will only be covered the specified number of times in the specified time period regardless of the treatment area. For example, if you set D2330 to be covered once per year, and then you post multiple D2330s with different tooth numbers and surfaces, insurance estimates will show that only the first D2330 is covered because teeth and surfaces are ignored for the frequency exception.

        • For a "Downgrade" exception type, in the Downgrade to search box, begin entering the code or description of the substitute procedure, continue typing as needed to narrow the results, and then select the correct code.

        • For an "Age limitation" exception type, set up the following options:

          • Age limitation - Enter a minimum age limit (as young as 0 years) and a maximum age limit (as old as 110+ years) to specify that the insurance carrier covers this procedure only for patients whose age is within the specified limit. Also, you can use the left slider to change the minimum age and the right slider to change the maximum age.

            Note: If the patient's age is not within the specified limit, the percentage (%) or copayment ($) in the coverage table is used.

          • Coverage, % or Downgrade - Do one of the following:

            • Specify a coverage percentage - Select the Coverage, % option. In the box, enter the percentage of the fee charged that the insurance carrier covers for this procedure.

              Note: The Coverage, % box is available only for coverage tables that are based on insurance coverage percentages.

            • Specify a downgrade - Select the Downgrade to option. In the Search for procedure box, begin entering the code or description of the substitute procedure, continue typing as needed to narrow the results, and then select the correct code.

          • Copayment, $ or Downgrade - Do one of the following:

            • Specify a copayment - Select the Copayment, $ option. Enter the co-pay that the patient pays for this procedure.

              Note: The Copayment, $ box is available only for coverage tables that are based on fixed, patient copayments.

            • Specify a downgrade - Select the Downgrade to option. In the Search for procedure box, begin entering the code or description of the substitute procedure, continue typing as needed to narrow the results, and then select the correct code.

          • Deductible Type - If the patient must pay a deductible for this procedure, select this checkbox, and then select the correct type of deductible from the corresponding list.

            Note: The Deductible Type checkbox is available only if the Coverage, % or Copayment, $ option is selected.

      2. Click (or tap) Next.

    • Reason for Exception

      In the box, enter the reason for the exception in coverage for this procedure.

  6. Click (or tap) Done.

    Note: This button is available only if the Reason for Exception tab is selected.