Understanding how insurance estimates are calculated

Dentrix Ascend calculates insurance portions, write-off adjustments, and patient portions automatically. The explanation that follows covers estimates for primary and secondary plans. The same rules and calculations that apply to secondary plans apply to plans for other coverage orders (tertiary, quaternary, and so forth); however, the calculations are not performed automatically.

The commercial insurance plans that Dentrix Ascend supports are PPO (Preferred Provider Organization), DHMO (Dental Health Maintenance Organization), and indemnity.

Notes:

Before calculating insurance estimates for procedures posted on the current date, Dentrix Ascend takes into account any pending primary and secondary claims (in the order they were sent, and claims with the highest total billed amount being handled first) for the patient, the subscriber of the patient's plan (if not the same person), and any other dependents on the plan. However, insurance estimates do not take into account a tertiary plan unless a claim for that plan is attached to a secondary claim; likewise, estimates do not take into account a quaternary plan unless a claim for that plan is attached to a tertiary claim; and so forth.
Dentrix Ascend processes procedures being billed to insurance chronologically (oldest to newest, by procedure dates), by descending procedure predetermination or override amounts (largest to smallest), and then by descending procedure amounts (largest to smallest).
When calculating estimates for an insurance payment, Dentrix Ascend processes only the procedures associated with the current claim. The maximums and deductibles are calculated as if the current claim is the next one to be paid.
For Dentrix Ascend to calculate estimates for procedures posted on the current date, the patient must have an active primary insurance plan with coverage dates that include the dates of those posted procedures.
Estimates include procedures posted on the current date and prior, even if those procedures are not attached to a claim.
The deductible type for multiple procedures posted on the same date is determined by the first procedure.
The billing provider, which is determined by the insurance defaults, may be different from the provider who is associated with a procedure.
Patient payments and credit adjustments that are applied to procedures reduce the estimated patient portion. Insurance payments that are less than what is expected to be paid reduce the estimated insurance portion and increase the estimated patient portion. Partial insurance payments (more is expected to be paid) reduce the estimated insurance portion.

Estimates for a patient's primary or only insurance plan

Do the following:

Calculate the Write-off.

Terms
W	Write-off
A_proc	Amount Charged (the procedure's Amount)
A_max	Max Allowable Amount (from the plan's Max allowable amount fee schedule)
A_pay	Payment Table Amount (from the Amount column in the plan's payment table)
C_pat	Patient Copay (from the Copayment $ column in the plan's coverage table)

Do one of the following:

If a Max allowable amount fee schedule is selected for the plan, do one of the following:
- If the billing provider is contracted with the carrier, do one of the following:
  - If a procedure is listed in the payment table, take the greater of A_max and A_pay, subtract that greater amount from A_proc, and then set W equal to that difference unless that difference is less than zero, in which case, set W equal to zero.
    
    W = max (0 ; A_proc - max (A_max ; A_pay))
  - If a procedure is not listed in the payment table, do one of the following:
    - For a coverage table based on patient copayments ($), take the greater of A_max and C_pat, subtract that greater amount from A_proc, and then set W equal to that difference unless that difference is less than zero, in which case, set W equal to zero.
      
      W = max (0 ; A_proc - max (A_max ; C_pat))
    - For a coverage table based on insurance coverage percentages (%), subtract A_max from A_proc, and then set W_pri equal to that difference unless that difference is less than zero, in which case, set W_pri equal to zero.
      
      W = max (0 ; A_proc - A_max)
- If the billing provider is not contracted with the carrier, set W equal to zero.
  
  W = 0
If a Max allowable amount fee schedule is not selected for the plan, there is not a Write-off, so set W equal to zero.

W = 0

Calculate the Remaining Deductible.

Term
D_rem	Remaining Deductible

Note: No value or a zero (0) for a required deductible both indicate that no deductible is required.

Do one of the following:

For an orthodontic procedure, do the following:

Calculate the Remaining Annual Individual Ortho Deductible:

Terms
AIOD_req	Required Annual Individual Ortho Deductible
AIOD_met	Met Annual Individual Ortho Deductible
AIOD_rem	Remaining Annual Individual Ortho Deductible

If AIOD_req has no value, then AIOD_rem = 0
If AIOD_req = 0, then AIOD_rem = 0
If AIOD_req > 0, then AIOD_rem = AIOD_req - AIOD_met

Set the Remaining Deductible (D_rem) equal to the Remaining Annual Individual Ortho Deductible (AIOD_rem).

D_rem = AIOD_rem

For a non-orthodontic procedure, do the following:

For the Lifetime Individual Deductible, calculate the Remaining Lifetime Individual Deductible:

Terms
LID_req	Required Lifetime Individual Deductible
LID_met	Met Lifetime Individual Deductible
LID_rem	Remaining Lifetime Individual Deductible

If LID_req has no value, then LID_rem = 0
If LID_req = 0, then LID_rem = 0
If LID_req > 0, then LID_rem = LID_req - LID_met

For the Annual Family Deductible, calculate the Remaining Annual Family Deductible:

Terms
AFD_req	Required Annual Family Deductible
AFD_met	Met Annual Family Deductible
AFD_rem	Remaining Annual Family Deductible

If AFD_req has no value, then AFD_rem = 0
If AFD_req = 0, then AFD_rem = 0
If AFD_req > 0, then AFD_rem = AFD_req - AFD_met

For the Annual Individual Deductible, calculate the Remaining Annual Individual Deductible:

Terms
AID_req	Required Annual Individual Deductible
AID_met	Met Annual Individual Deductible
AID_rem	Remaining Annual Individual Deductible

If AID_req has no value, then AID_rem = 0
If AID_req = 0, then AID_rem = 0
If AID_req > 0, then AID_rem = AID_req - AID_met

Calculate the Remaining Deductible. Take the lesser of LID_rem, AFD_rem, and AID_rem, and set D_rem equal to that lesser amount.

D_rem = min (LID_rem ; AFD_rem ; AID_rem)

Calculate the Insurance Portion.

Terms
I	Insurance Portion
A_proc	Amount Charged (the procedure's Amount)
A_max	Max Allowable Amount (from the plan's Max allowable amount fee schedule)
A_min	Min Allowable Amount
A_pay	Payment Table Amount (from the Amount column in the plan's payment table)
C_pat	Patient Copay (from the Copayment $ column in the plan's coverage table)
C_ins	Insurance Coverage Percentage (from the Coverage % column in the plan's coverage table)
C_exc	Patient Copay Exception or Insurance Coverage Exception (any applicable exceptions, as indicated in the EXC column, in the plan's coverage table)
O_ins	Insurance Estimate Override (from the procedure's Insurance Estimate Overrides; entered and locked automatically, or entered manually)

Do one of the following:

If a Max allowable amount fee schedule is selected for the plan, do the following:
1. Calculate the Min Allowable. Because the calculations for the Insurance Portion require that A_max not exceed A_proc, take the lesser of A_proc and A_max, and then set A_min equal to that lesser amount.
  
  A_min = min (A_proc ; A_max)
2. Calculate the Insurance Portion. Do one of the following:
  - Without an Insurance Estimate Override, do one of the following:
    - If a procedure is listed in the payment table, take the greater of A_min and A_pay, and then set I equal to that greater amount.
      
      I = max (A_min ; A_pay)
    - If a procedure is not listed in the payment table, do one of the following:
      - For a coverage table based on patient copayments, do the following:
        
        Determine the Patient Copay. Do one of the following:
        
        If there is an exception for the procedure in the coverage table, use one of the following exception types to determine the copay:
        
        Not covered. The carrier does not have a portion, so set C_pat equal to A_min.
        
        C_pat = A_min
        
        Coverage with Maximum Age Limit. Do one of the following:
        
        If the patient's age does not exceed the specified age, use the exception instead of the default copay.
        
        C_pat = C_exc
        
        If the patient's age exceeds the specified age, use the default copay.
        
        C_pat = C_pat
        
        Downgrade. Use the exception instead of the default copay.
        
        C_pat = C_exc
        
        If there is not an exception for the procedure in the coverage table, use the default copay.
        
        C_pat = C_pat
        
        Calculate the Insurance Portion. Subtract C_pat from A_min, and then set I equal to that difference unless that difference is less than zero, in which case, set I equal to zero.
        
        I = max (0 ; A_min - C_pat)
      - For a coverage table based on insurance coverage percentages, do the following:
        
        Determine the Insurance Coverage Percentage. Do one of the following:
        
        If there is an exception for the procedure in the coverage table, use one of the following exception types to determine the coverage:
        
        Not covered. The carrier does not have a portion, so set C_ins equal to zero.
        
        C_ins = 0
        
        Coverage with Maximum Age Limit. Do one of the following:
        
        If the patient's age does not exceed the specified age, use the exception instead of the default coverage.
        
        C_ins = C_exc
        
        If the patient's age exceeds the specified age, use the default coverage.
        
        C_ins = C_ins
        
        Downgrade. Use the exception instead of the default coverage.
        
        C_ins = C_exc
        
        If there is not an exception for the procedure in the coverage table, use the default coverage.
        
        C_ins = C_ins
        
        Calculate the Insurance Portion. Multiply A_min and C_ins, and then set I equal to that product unless that product is less than zero, in which case, set I equal to zero.
        
        I = max (0 ; A_min x C_ins)
  - With an Insurance Estimate Override, take the greater of O_ins and A_min, and then set I equal to that greater amount unless that greater amount is less than zero, in which case, set I equal to zero.
    
    I = max (0 ; min (O_ins ; A_min))
If a Max allowable amount fee schedule is not selected for the plan, do one of the following:
- Without an Insurance Estimate Override, do one of the following:
  - If a procedure is listed in the payment table, set I equal to A_pay.
    
    I = A_pay
  - If a procedure is not listed in the payment table, do one of the following:
    - For a coverage table based on patient copayments, do the following:
      1. Determine the Patient Copay. Do one of the following:
        
        If there is an exception for the procedure in the coverage table, use one of the following exception types to determine the copay:
        
        Not covered. The carrier does not have a portion, so set C_pat equal to A_proc.
        
        C_pat = A_proc
        
        Coverage with Maximum Age Limit. Do one of the following:
        
        If the patient's age does not exceed the specified age, use the exception instead of the default copay.
        
        C_pat = C_exc
        
        If the patient's age exceeds the specified age, use the default copay.
        
        C_pat = C_pat
        
        Downgrade. Use the exception instead of the default copay.
        
        C_pat = C_exc
        
        If there is not an exception for the procedure in the coverage table, use the default copay.
        
        C_pat = C_pat
      2. Calculate the Insurance Portion. Subtract C_pat from A_proc, and then set I equal to that difference.
        
        I = A_proc - C_pat
    - For a coverage table based on insurance coverage percentages, do the following:
      1. Determine the Insurance Coverage Percentage. Do one of the following:
        
        If there is an exception for the procedure in the coverage table, use one of the following exception types to determine the coverage:
        
        Not covered. The carrier does not have a portion, so set C_ins equal to zero.
        
        C_ins = 0
        
        Coverage with Maximum Age Limit. Do one of the following:
        
        If the patient's age does not exceed the specified age, use the exception instead of the default coverage.
        
        C_ins = C_exc
        
        If the patient's age exceeds the specified age, use the default coverage.
        
        C_ins = C_ins
        
        Downgrade. Use the exception instead of the default coverage.
        
        C_ins = C_exc
        
        If there is not an exception for the procedure in the coverage table, use the default coverage.
        
        C_ins = C_ins
      2. Calculate the Insurance Portion. Multiply A_proc and C_ins, and then set I equal to that product.
        
        I = A_proc x C_ins
- With an Insurance Estimate Override, set I equal to the override.
  
  I = O_ins

Calculate the Patient Portion.

Terms
P	Patient Portion
A_proc	Amount Charged (the procedure's Amount)
I	Insurance Portion
W	Write-off

Subtract I and W from A_proc, and then set P equal to that difference.

P = A_proc - I - W

Use the Remaining Deductible to adjust the Insurance Portion and the Patient Portion as needed.

Terms
I	Insurance Portion
P	Patient Portion
D_rem	Remaining Deductible

Do the following:

Subtract D_rem from I, and then set I equal to that difference.

I = I - D_rem
Add P and D_rem, and then set P equal to that sum.

P = P + D_rem

Calculate the Remaining Benefit.

Term
B_rem	Remaining Benefit

Note: No value for a maximum indicates unlimited benefits; zero (0) indicates no benefits.

Do one of the following:

For an orthodontic procedure, do the following:

Calculate the Remaining Lifetime Ortho Benefit:

Terms
LOB_max	Maximum Lifetime Ortho Benefit
LOB_used	Used Lifetime Ortho Benefit
LOB_rem	Remaining Lifetime Ortho Benefit

If LOB_max has no value, then LOB_rem = 9,999,999.99
If LOB_max = 0, then LOB_rem = 0
If LOB_max > 0, then LOB_rem = LOB_max - LOB_used

Set the Remaining Benefit (B_rem) equal to the Remaining Lifetime Ortho Benefit (LOB_rem).

B_rem = LOB_rem

For a non-orthodontic procedure, do the following:

Calculate the Remaining Annual Individual Benefit:

Terms
AIB_max	Maximum Annual Individual Benefit
AIB_used	Used Annual Individual Benefit
AIB_rem	Remaining Annual Individual Benefit

If AIB_max has no value, then AIB_rem = 9,999,999.99
If AIB_max = 0, then AIB_rem = 0
If AIB_max > 0, then AIB_rem = AIB_max - AIB_used

Calculate the Remaining Annual Family Benefit:

Terms
AFB_max	Maximum Annual Family Benefit
AFB_used	Used Annual Family Benefit
AFB_rem	Remaining Annual Family Benefit

If AFB_max has no value, then AFB_rem = 9,999,999.99
If AFB_max = 0, then AFB_rem = 0
If AFB_max > 0, then AFB_rem = AFB_max - AFB_used

Calculate the Remaining Benefit. Take the lesser of AIB_rem and AFB_rem, and then set B_rem equal to that lesser amount.

B_rem = min (AIB_rem ; AFB_rem)

Use the Remaining Benefit to adjust the Insurance Portion and the Patient Portion as needed.

Terms
I	Insurance Portion
B_rem	Remaining Benefit
P	Patient Portion
B_over	Benefit Overage

Recalculate the Insurance Portion and the Patient Portion. Do one of the following:

If I <= B_rem, there is enough remaining benefit to cover the entire amount that is expected to be paid by the carrier.
- The Insurance Portion does not change.
  
  I = I
- The Patient Portion does not change.
  
  P = P
If I > B_rem, the remaining benefits covers none or only a portion of the amount that is expected to be paid by the carrier, so do the following:
1. Calculate the Benefit Overage.
  
  B_over = I - B_rem
2. Recalculate the Insurance Portion. Set I equal to B_rem.
  
  I = B_rem
3. Recalculate the Patient Portion. Add P and B_over, and then set P equal to that sum.
  
  P = P + B_over

Estimates for dual coverage

Do the following:

Calculate the Primary Write-off.

Terms
W_pri	Primary Write-off
A_proc	Amount Charged (the procedure's Amount)
A_P.max	Primary Max Allowable Amount (from the plan's Max allowable amount fee schedule)
A_P.pay	Primary Payment Table Amount (from the Amount column in the plan's payment table)
C_P.pat	Primary Patient Copay (from the Copayment $ column in the plan's coverage table)

Do one of the following:

If a Max allowable amount fee schedule is selected for the plan, do one of the following:
- If the billing provider is contracted with the carrier, do one of the following:
  - If a procedure is listed in the payment table, take the greater of A_P.max and A_P.pay, subtract that greater amount from A_proc, and then set W_priequal to that difference unless that difference is less than zero, in which case, set W equal to zero.
    
    W_pri = max (0 ; A_proc - max (A_P.max ; A_P.pay))
  - If a procedure is not listed in the payment table, do one of the following:
    - For a coverage table based on patient copayments ($), take the greater of A_P.max and C_P.pat, subtract that from A_proc, and then set W_pri equal to that difference unless that difference is less than zero, in which case, set W_pri equal to zero.
      
      W_pri = max (0 ; A_proc - max (A_P.max ; C_P.pat))
    - For a coverage table based on insurance coverage percentages (%), subtract A_P.max from A_proc, and then set W_pri equal to that difference unless that difference is less than zero, in which case, set W_pri equal to zero.
      
      W_pri = max (0 ; A_proc - A_P.max)
- If the billing provider is not contracted with the carrier, set W_pri equal to zero.
  
  W_pri = 0
If a Max allowable amount fee schedule is not selected for the plan, there is not a Primary Write-off, so set W_pri equal to zero.

W_pri = 0

Calculate the Secondary Write-off.

Terms
W_sec	Secondary Write-off
A_proc	Amount Charged (the procedure's Amount)
A_S.max	Secondary Max Allowable Amount (from the plan's Max allowable amount fee schedule)
A_S.pay	Secondary Payment Table Amount (from the Amount column in the plan's payment table)
C_S.pat	Secondary Patient Copay (from the Copayment $ column in the plan's coverage table)

Do one of the following:

If a Max allowable amount fee schedule is selected for the plan, do one of the following:
- If the billing provider is contracted with the carrier, do one of the following:
  - If a procedure is listed in the payment table, take the greater of A_S.max and A_S.pay, subtract that greater amount from A_proc, and then set W_secequal to that difference unless that difference is less than zero, in which case, set W equal to zero.
    
    W_sec = max (0 ; A_proc - max (A_S.max ; A_S.pay))
  - If a procedure is not listed in the payment table, do one of the following:
    - For a coverage table based on patient copayments ($), take the greater of A_S.max and C_S.pat, subtract that from A_proc, and then set W_sec equal to that difference unless that difference is less than zero, in which case, set W_sec equal to zero.
      
      W_sec = max (0 ; A_proc - max (A_S.max ; C_S.pat))
    - For a coverage table based on insurance coverage percentages (%), subtract A_S.max from A_proc, and then set W_sec equal to that difference unless that difference is less than zero, in which case, set W_sec equal to zero.
      
      W_sec = max (0 ; A_proc - A_S.max)
- If the billing provider is not contracted with the carrier, set W_sec equal to zero.
  
  W_sec = 0
If a Max allowable amount fee schedule is not selected for the plan, there is not a Secondary Write-off, so set W_sec equal to zero.

W_sec = 0

Calculate the Max Write-off.

Terms
W_max	Max Write-off
W_pri	Primary Write-off
W_sec	Secondary Write-off

Take the greater of W_pri and W_sec, and then set W_max equal to that greater amount.

W_max = max (W_pri ; W_sec)

Calculate the Primary Remaining Deductible.

Term
D_P.rem	Primary Remaining Deductible

Note: No value or a zero (0) for a required deductible both indicate that no deductible is required.

Do one of the following:

For an orthodontic procedure, do the following:

Calculate the Primary Remaining Annual Individual Ortho Deductible:

Terms
AIOD_P.req	Primary Required Annual Individual Ortho Deductible
AIOD_P.met	Primary Met Annual Individual Ortho Deductible
AIOD_P.rem	Primary Remaining Annual Individual Ortho Deductible

If AIOD_P.req has no value, then AIOD_P.rem = 0
If AIOD_P.req = 0, then AIOD_P.rem = 0
If AIOD_P.req > 0, then AIOD_P.rem = AIOD_P.req - AIOD_P.met

Set the Primary Remaining Deductible (D_P.rem) equal to the Primary Remaining Annual Individual Ortho Deductible (AIOD_P.rem).

D_P.rem = AIOD_P.rem

For a non-orthodontic procedure, do the following:

For the Lifetime Individual Deductible, calculate the Primary Remaining Lifetime Individual Deductible:

Terms
LID_P.req	Primary Required Lifetime Individual Deductible
LID_P.met	Primary Met Lifetime Individual Deductible
LID_P.rem	Primary Remaining Lifetime Individual Deductible

If LID_P.req has no value, then LID_P.rem = 0
If LID_P.req = 0, then LID_P.rem = 0
If LID_P.req > 0, then LID_P.rem = LID_P.req - LID_P.met

For the Annual Family Deductible, calculate the Primary Remaining Annual Family Deductible:

Terms
AFD_P.req	Primary Required Annual Family Deductible
AFD_P.met	Primary Met Annual Family Deductible
AFD_P.rem	Primary Remaining Annual Family Deductible

If AFD_P.req has no value, then AFD_P.rem = 0
If AFD_P.req = 0, then AFD_P.rem = 0
If AFD_P.req > 0, then AFD_P.rem = AFD_P.req - AFD_P.met

For the Annual Individual Deductible, calculate the Primary Remaining Annual Individual Deductible:

Terms
AID_P.req	Primary Required Annual Individual Deductible
AID_P.met	Primary Met Annual Individual Deductible
AID_P.rem	Primary Remaining Annual Individual Deductible

If AID_P.req has no value, then AID_P.rem = 0
If AID_P.req = 0, then AID_P.rem = 0
If AID_P.req > 0, then AID_P.rem = AID_P.req - AID_P.met

Calculate the Primary Remaining Deductible. Take the lesser of LID_P.rem, AFD_P.rem, and AID_P.rem, and set D_P.rem equal to that lesser amount.

D_P.rem = min (LID_P.rem ; AFD_P.rem ; AID_P.rem)

Calculate the Primary Insurance Portion.

Terms
I_pri	Primary Insurance Portion
A_proc	Amount Charged (the procedure's Amount)
A_P.max	Primary Max Allowable Amount (from the plan's Max allowable amount fee schedule)
A_P.min	Primary Min Allowable Amount
A_P.pay	Primary Payment Table Amount (from the Amount column in the plan's payment table)
C_P.pat	Primary Patient Copay (from the Copayment $ column in the plan's coverage table)
C_P.ins	Primary Insurance Coverage Percentage (from the Coverage % column in the plan's coverage table)
C_P.exc	Primary Patient Copay Exception or Primary Insurance Coverage Exception (any applicable exceptions, as indicated in the EXC column, in the plan's coverage table)
O_P.ins	Primary Insurance Estimate Override (from the procedure's Insurance Estimate Overrides; entered and locked automatically, or entered manually)

Do one of the following:

If a Max allowable amount fee schedule is selected for the plan, do the following:
1. Calculate the Primary Min Allowable. Because the calculations for the Primary Insurance Portion require that A_P.max not exceed A_proc, take the lesser of A_proc and A_P.max, and then set A_P.min equal to that lesser amount.
  
  A_P.min = min (A_proc ; A_P.max)
2. Calculate the Primary Insurance Portion. Do one of the following:
  - Without a Primary Insurance Estimate Override, do one of the following:
    - If a procedure is listed in the payment table, take the greater of A_P.min and A_P.pay, and then set I_pri equal to that greater amount.
      
      I_pri = max (A_P.min ; A_P.pay)
    - If a procedure is not listed in the payment table, do one of the following:
      - For a coverage table based on patient copayments, do the following:
        
        Determine the Primary Patient Copay. Do one of the following:
        
        If there is an exception for the procedure in the coverage table, use one of the following exception types to determine the copay:
        
        Not covered. The carrier does not have a portion, so set C_P.pat equal to A_P.min.
        
        C_P.pat = A_P.min
        
        Coverage with Maximum Age Limit. Do one of the following:
        
        If the patient's age does not exceed the specified age, use the exception instead of the default copay.
        
        C_P.pat = C_P.exc
        
        If the patient's age exceeds the specified age, use the default copay.
        
        C_P.pat = C_P.pat
        
        Downgrade. Use the exception instead of the default copay.
        
        C_P.pat = C_P.exc
        
        If there is not an exception for the procedure in the coverage table, use the default copay.
        
        C_P.pat = C_P.pat
        
        Calculate the Primary Insurance Portion. Subtract C_P.pat from A_P.min, and then set I_pri equal to that difference unless that difference is less than zero, in which case, set I_pri equal to zero.
        
        I_pri = max (0 ; A_P.min - C_P.pat)
      - For a coverage table based on insurance coverage percentages, do the following:
        
        Determine the Primary Insurance Coverage Percentage. Do one of the following:
        
        If there is an exception for the procedure in the coverage table, use one of the following exception types to determine the coverage:
        
        Not covered. The carrier does not have a portion, so set C_P.ins equal to zero.
        
        C_P.ins = 0
        
        Coverage with Maximum Age Limit. Do one of the following:
        
        If the patient's age does not exceed the specified age, use the exception instead of the default coverage.
        
        C_P.ins = C_P.exc
        
        If the patient's age exceeds the specified age, use the default coverage.
        
        C_P.ins = C_P.ins
        
        Downgrade. Use the exception instead of the default coverage.
        
        C_P.ins = C_P.exc
        
        If there is not an exception for the procedure in the coverage table, use the default coverage.
        
        C_P.ins = C_P.ins
        
        Calculate the Primary Insurance Portion. Multiply A_P.min and C_P.ins, and then set I_pri equal to that product unless that product is less than zero, in which case, set I_pri equal to zero.
        
        I_pri = max (0 ; A_P.min x C_P.ins)
  - With a Primary Insurance Estimate Override, take the greater of O_P.ins and A_P.min, and then set I_pri equal to that greater amount unless that greater amount is less than zero, in which case, set I_pri equal to zero.
    
    I_pri = max (0 ; min (O_P.ins ; A_P.min))
If a Max allowable amount fee schedule is not selected for the plan, do one of the following:
- Without a Primary Insurance Estimate Override, do one of the following:
  - If a procedure is listed in the payment table, set I_pri equal to A_P.pay.
    
    I_pri = A_P.pay
  - If a procedure is not listed in the payment table, do one of the following:
    - For a coverage table based on patient copayments, do the following:
      1. Determine the Primary Patient Copay. Do one of the following:
        
        If there is an exception for the procedure in the coverage table, use one of the following exception types to determine the copay:
        
        Not covered. The carrier does not have a portion, so set C_P.pat equal to A_proc.
        
        C_P.pat = A_proc
        
        Coverage with Maximum Age Limit. Do one of the following:
        
        If the patient's age does not exceed the specified age, use the exception instead of the default copay.
        
        C_P.pat = C_P.exc
        
        If the patient's age exceeds the specified age, use the default copay.
        
        C_P.pat = C_P.pat
        
        Downgrade. Use the exception instead of the default copay.
        
        C_P.pat = C_P.exc
        
        If there is not an exception for the procedure in the coverage table, use the default copay.
        
        C_P.pat = C_P.pat
      2. Calculate the Primary Insurance Portion. Subtract C_P.pat from A_proc, and then set I_pri equal to that difference.
        
        I_pri = A_proc - C_P.pat
    - For a coverage table based on insurance coverage percentages, do the following:
      1. Determine the Primary Insurance Coverage. Do one of the following:
        
        If there is an exception for the procedure in the coverage table, use one of the following exception types to determine the coverage:
        
        Not covered. The carrier does not have a portion, so set C_P.ins equal to zero.
        
        C_P.ins = 0
        
        Coverage with Maximum Age Limit. Do one of the following:
        
        If the patient's age does not exceed the specified age, use the exception instead of the default coverage.
        
        C_P.ins = C_P.exc
        
        If the patient's age exceeds the specified age, use the default coverage.
        
        C_P.ins = C_P.ins
        
        Downgrade. Use the exception instead of the default coverage.
        
        C_P.ins = C_P.exc
        
        If there is not an exception for the procedure in the coverage table, use the default coverage.
        
        C_P.ins = C_P.ins
      2. Calculate the Primary Insurance Portion. Multiply A_proc and C_P.ins, and then set I_pri equal to that product.
        
        I_pri = A_proc x C_P.ins
- With a Primary Insurance Estimate Override, set I_pri equal to the override.
  
  I_pri = O_P.ins

Use the Primary Remaining Deductible to set the Max Primary Insurance Portion.

Terms
I_P.max	Max Primary Insurance Portion
I_pri	Primary Insurance Portion
D_P.rem	Primary Remaining Deductible

Subtract D_P.rem from I_pri, and then set I_P.max equal to that difference.

I_P.max = I_pri - D_P.rem

Calculate the Primary Remaining Benefit.

Term
B_P.rem	Primary Remaining Benefit

Note: No value for a maximum indicates unlimited benefits; zero (0) indicates no benefits.

Do one of the following:

For an orthodontic procedure, do the following:

Calculate the Primary Remaining Lifetime Ortho Benefit:

Terms
LOB_P.max	Primary Maximum Lifetime Ortho Benefit
LOB_P.used	Primary Used Lifetime Ortho Benefit
LOB_P.rem	Primary Remaining Lifetime Ortho Benefit

If LOB_P.max has no value, then LOB_P.rem = 9,999,999.99
If LOB_P.max = 0, then LOB_P.rem = 0
If LOB_P.max > 0, then LOB_P.rem = LOB_P.max - LOB_P.used

Set the Primary Remaining Benefit (B_P.rem) equal to the Primary Remaining Lifetime Ortho Benefit (LOB_P.rem).

B_P.rem = LOB_P.rem

For a non-orthodontic procedure, do the following:

Calculate the Primary Remaining Annual Individual Benefit:

Terms
AIB_P.max	Primary Maximum Annual Individual Benefit
AIB_P.used	Primary Used Annual Individual Benefit
AIB_P.rem	Primary Remaining Annual Individual Benefit

If AIB_P.max has no value, then AIB_P.rem = 9,999,999.99
If AIB_P.max = 0, then AIB_P.rem = 0
If AIB_P.max > 0, then AIB_P.rem = AIB_P.max - AIB_P.used

Calculate the Primary Remaining Annual Family Benefit:

Terms
AFB_P.max	Primary Maximum Annual Family Benefit
AFB_used	Primary Used Annual Family Benefit
AFB_rem	Primary Remaining Annual Family Benefit

If AFB_P.max has no value, then AFB_P.rem = 9,999,999.99
If AFB_P.max = 0, then AFB_P.rem = 0
If AFB_P.max > 0, then AFB_P.rem = AFB_P.max - AFB_P.used

Calculate the Primary Remaining Benefit. Take the lesser of AIB_P.rem and AFB_P.rem, and then set B_P.rem equal to that lesser amount.

B_P.rem = min (AIB_P.rem ; AFB_P.rem)

Use the Primary Remaining Benefit to adjust the Max Primary Insurance Portion as needed.

Terms
I_P.max	Max Primary Insurance Portion
B_P.rem	Primary Remaining Benefit

Do one of the following:

If I_P.max <= B_P.rem, there is enough remaining benefit to cover the entire amount that is expected to be paid by the carrier. The Max Primary Insurance Portion does not change.

I_P.max = I_P.max
If I_P.max > B_P.rem, the remaining benefits covers none or only a portion of the amount that is expected to be paid by the carrier. Set the Max Primary Insurance Portion (I_P.max) equal to the Primary Remaining Benefit (B_P.rem).

I_P.max = B_P.rem

Calculate the Secondary Remaining Deductible.

Term
D_S.rem	Secondary Remaining Deductible

Note: No value or a zero (0) for a required deductible both indicate that no deductible is required.

Do one of the following:

For an orthodontic procedure, do the following:

Calculate the Secondary Remaining Annual Individual Ortho Deductible:

Terms
AIOD_S.req	Secondary Required Annual Individual Ortho Deductible
AIOD_S.met	Secondary Met Annual Individual Ortho Deductible
AIOD_S.rem	Secondary Remaining Annual Individual Ortho Deductible

If AIOD_S.req has no value, then AIOD_S.rem = 0
If AIOD_S.req = 0, then AIOD_S.rem = 0
If AIOD_S.req > 0, then AIOD_S.rem = AIOD_S.req - AIOD_S.met

Set the Secondary Remaining Deductible (D_S.rem) equal to the Secondary Remaining Annual Individual Ortho Deductible (AIOD_S.rem).

D_S.rem = AIOD_S.rem

For a non-orthodontic procedure, do the following:

For the Lifetime Individual Deductible, calculate the Secondary Remaining Lifetime Individual Deductible:

Terms
LID_S.req	Secondary Required Lifetime Individual Deductible
LID_S.met	Secondary Met Lifetime Individual Deductible
LID_S.rem	Secondary Remaining Lifetime Individual Deductible

If LID_S.req has no value, then LID_S.rem = 0
If LID_S.req = 0, then LID_S.rem = 0
If LID_S.req > 0, then LID_S.rem = LID_S.req - LID_S.met

For the Annual Family Deductible, calculate the Secondary Remaining Annual Family Deductible:

Terms
AFD_S.req	Secondary Required Annual Family Deductible
AFD_S.met	Secondary Met Annual Family Deductible
AFD_S.rem	Secondary Remaining Annual Family Deductible

If AFD_S.req has no value, then AFD_S.rem = 0
If AFD_S.req = 0, then AFD_S.rem = 0
If AFD_S.req > 0, then AFD_S.rem = AFD_S.req - AFD_S.met

For the Annual Individual Deductible, calculate the Secondary Remaining Annual Individual Deductible:

Terms
AID_S.req	Secondary Required Annual Individual Deductible
AID_S.met	Secondary Met Annual Individual Deductible
AID_S.rem	Secondary Remaining Annual Individual Deductible

If AID_S.req has no value, then AID_S.rem = 0
If AID_S.req = 0, then AID_S.rem = 0
If AID_S.req > 0, then AID_S.rem = AID_S.req - AID_S.met

Calculate the Secondary Remaining Deductible. Take the lesser of LID_S.rem, AFD_S.rem, and AID_S.rem, and set D_S.rem equal to that lesser amount.

D_S.rem = min (LID_S.rem ; AFD_S.rem ; AID_S.rem)

Calculate the Secondary Insurance Portion.

Terms
I_sec	Secondary Insurance Portion
A_proc	Amount Charged (the procedure's Amount)
A_S.max	Secondary Max Allowable Amount (from the secondary plan's Max allowable amount fee schedule)
A_S.min	Secondary Min Allowable Amount
A_S.pay	Secondary Payment Table Amount (from the Amount column in the plan's payment table)
C_S.pat	Secondary Patient Copay (from the Copayment $ column in the secondary plan's coverage table)
C_S.ins	Secondary Insurance Coverage Percentage (from the Coverage % column in the secondary plan's coverage table)
C_S.exc	Secondary Patient Copay Exception or Secondary Insurance Coverage Exception (any applicable exceptions, as indicated in the EXC column, in the secondary plan's coverage table)
O_S.ins	Secondary Insurance Estimate Override (from the procedure's Insurance Estimate Overrides; entered and locked automatically, or entered manually)

Do one of the following:

If a Max allowable amount fee schedule is selected for the plan, do the following:
1. Calculate the Secondary Min Allowable. Because the calculations for the Secondary Insurance Portion require that A_S.max not exceed A_proc, take the lesser of A_proc and A_S.max, and then set A_S.min equal to that lesser amount.
  
  A_S.min = min (A_proc ; A_S.max)
2. Calculate the Secondary Insurance Portion. Do one of the following:
  - Without a Secondary Insurance Estimate Override:
    - If a procedure is listed in the payment table, take the greater of A_S.min and A_S.pay, and then set I_sec equal to that greater amount.
      
      I_sec = max (A_S.min ; A_S.pay)
    - If a procedure is not listed in the payment table, do one of the following:
      - For a coverage table based on patient copayments, do the following:
        
        Determine the Secondary Patient Copay.
        
        If there is an exception for the procedure in the coverage table, use one of the following exception types:
        
        Not covered. The carrier does not have a portion, so set C_S.pat equal to A_S.min.
        
        C_S.pat = A_S.min
        
        Coverage with Maximum Age Limit. Do one of the following:
        
        If the patient's age does not exceed the specified age, use the exception instead of the default copay.
        
        C_S.pat = C_S.exc
        
        If the patient's age exceeds the specified age, use the default copay.
        
        C_S.pat = C_S.pat
        
        Downgrade. Use the exception instead of the default copay.
        
        C_S.pat = C_S.exc
        
        If there is not an exception for the procedure in the coverage table, use the default copay.
        
        C_S.pat = C_S.pat
        
        Calculate the Secondary Insurance Portion. Use one of the following methods for coordinating benefits:
        
        Traditional: Subtract C_S.pat from A_S.min, and then set I_sec equal to that difference unless that difference is less than zero, in which case, set I_sec equal to zero.
        
        I_sec = max (0; A_S.min - C_S.pat)
        
        Maintenance of Benefits: Subtract W_sec, I_pri, and C_S.pat from A_proc, and then set I_sec equal to that difference unless that difference is less than zero, in which case, set I_sec equal to zero.
        
        I_sec = max (0 ; A_proc - W_sec - I_pri - C_S.pat)
        
        Carve Out/Non-duplication: Subtract C_S.pat and I_pri from A_S.min, and then set I_sec equal to that difference unless that difference is less than zero, in which case, set I_sec equal to zero.
        
        I_sec = max (0 ; A_S.min - C_S.pat - I_pri)
      - For a coverage table based on insurance coverage percentages, do the following:
        
        Determine the Secondary Insurance Coverage Percentage. Do one of the following:
        
        If there is an exception for the procedure in the coverage table, use the following exception types to determine the coverage:
        
        Not covered. The carrier does not have a portion, so set C_S.ins equal to zero.
        
        C_S.ins = 0
        
        Coverage with Maximum Age Limit. Do one of the following:
        
        If the patient's age does not exceed the specified age, use the exception instead of the default coverage.
        
        C_S.ins = C_S.exc
        
        If the patient's age exceeds the specified age, use the default coverage.
        
        C_S.ins = C_S.ins
        
        Downgrade. Use the exception instead of the default coverage.
        
        C_S.ins = C_S.exc
        
        If there is not an exception for the procedure in the coverage table, use the default coverage.
        
        C_S.ins = C_S.ins
        
        Calculate the Secondary Insurance Portion. Use one of the following methods for coordinating benefits:
        
        Traditional: Multiply A_S.min and C_S.ins, and then set I_sec equal to that product unless that product is less than zero, in which case, set I_sec equal to zero.
        
        I_sec = max (0 ; A_S.min x C_S.ins)
        
        Maintenance of Benefits: Subtract I_pri from A_S.min, multiply that difference and C_S.ins, and then set I_sec equal to the resulting product unless that product is less than zero, in which case, set I_sec equal to zero.
        
        I_sec = max (0 ; (A_S.min - I_pri) x C_S.ins)
        
        Carve Out/Non-duplication: Multiply A_S.min and C_S.ins, subtract I_pri from that product, and then set I_sec equal to the resulting difference unless that difference is less than zero, in which case, set I_sec equal to zero.
        
        I_sec = max (0 ; (A_S.min x C_S.ins) - I_pri)
  - With a Secondary Insurance Estimate Override, use one of the following methods for coordinating benefits:
    - Traditional: Take the greater of O_S.ins and A_S.min, and then set I_sec equal to that greater amount unless that greater amount is less than zero, in which case, set I_sec equal to zero.
      
      I_sec = max (0; min (O_S.ins ; A_S.min))
    - Maintenance of Benefits: Set I_sec equal to the override.
      
      I_sec = O_S.ins
    - Carve Out/Non-duplication: Set I_sec equal to the override.
      
      I_sec = O_S.ins
If a Max allowable amount fee schedule is not selected for the plan, do one of the following:
- Without a Secondary Insurance Estimate Override, do one of the following:
  - If a procedure is listed in the payment table, set I_sec equal to A_S.pay.
    
    I_sec = A_S.pay
  - If a procedure is not listed in the payment table, do one of the following:
    - For a coverage table based on patient copayments, do the following:
      1. Determine the Secondary Patient Copay.
        
        If there is an exception for the procedure in the coverage table, use one of the following exception types:
        
        Not covered. The carrier does not have a portion, so set C_S.pat equal to A_proc.
        
        C_S.pat = A_proc
        
        Coverage with Maximum Age Limit. Do one of the following:
        
        If the patient's age does not exceed the specified age, use the exception instead of the default copay.
        
        C_S.pat = C_S.exc
        
        If the patient's age exceeds the specified age, use the default copay.
        
        C_S.pat = C_S.pat
        
        Downgrade. Use the exception instead of the default copay.
        
        C_S.pat = C_S.exc
        
        If there is not an exception for the procedure in the coverage table, use the default copay.
        
        C_S.pat = C_S.pat
      2. Calculate the Secondary Insurance Portion. Use one of the following methods for coordinating benefits:
        
        Traditional: Subtract C_S.pat from A_proc, and then set I_sec equal to that difference.
        
        I_sec = A_proc - C_S.pat
        
        Maintenance of Benefits: Subtract I_pri and C_S.pat from A_proc, and then set I_sec equal to that difference.
        
        I_sec = A_proc - I_pri - C_S.pat
        
        Carve Out/Non-duplication: Subtract C_S.pat and I_pri from A_proc, and then set I_sec equal to that difference.
        
        I_sec = A_proc- C_S.pat - I_pri
    - For a coverage table based on insurance coverage percentages, do the following:
      1. Determine the Secondary Insurance Coverage Percentage. Do one of the following:
        
        If there is an exception for the procedure in the coverage table, use the following exception types to determine the coverage:
        
        Not covered. The carrier does not have a portion, so set C_S.ins equal to zero.
        
        C_S.ins = 0
        
        Coverage with Maximum Age Limit. Do one of the following:
        
        If the patient's age does not exceed the specified age, use the exception instead of the default coverage.
        
        C_S.ins = C_S.exc
        
        If the patient's age exceeds the specified age, use the default coverage.
        
        C_S.ins = C_S.ins
        
        Downgrade. Use the exception instead of the default coverage.
        
        C_S.ins = C_S.exc
        
        If there is not an exception for the procedure in the coverage table, use the default coverage.
        
        C_S.ins = C_S.ins
      2. Calculate the Secondary Insurance Portion. Use one of the following methods for coordinating benefits:
        
        Traditional: Multiply A_proc and C_S.ins, and then set I_sec equal to that product.
        
        I_sec = A_proc x C_S.ins
        
        Maintenance of Benefits: Subtract I_pri from A_proc, multiply that difference and C_S.ins, and then set I_sec equal to the resulting product.
        
        I_sec = (A_proc - I_pri) x C_S.ins
        
        Carve Out/Non-duplication: Multiply A_proc and C_S.ins, subtract I_pri from that product, and then set I_sec equal to that product.
        
        I_sec = (A_proc x C_S.ins) - I_pri
- With a Secondary Insurance Estimate Override, set I_sec equal to the override.
  
  I_sec = O_S.ins

Use the Secondary Remaining Deductible to set the Max Secondary Insurance Portion.

Terms
I_S.max	Max Secondary Insurance Portion
I_sec	Secondary Insurance Portion
D_S.rem	Secondary Remaining Deductible

Subtract D_S.rem from I_sec, and then set I_max equal to that difference.

I_max = I_sec - D_rem

Calculate the Secondary Remaining Benefit.

Terms
B_S.rem	Secondary Remaining Benefit

Note: No value for a maximum indicates unlimited benefits; zero (0) indicates no benefits.

Do one of the following:

For an orthodontic procedure, do the following:

Calculate the Secondary Remaining Lifetime Ortho Benefit:

Terms
LOB_S.max	Secondary Maximum Lifetime Ortho Benefit
LOB_S.used	Secondary Used Lifetime Ortho Benefit
LOB_S.rem	Secondary Remaining Lifetime Ortho Benefit

If LOB_S.max has no value, then LOB_S.rem = 9,999,999.99
If LOB_S.max = 0, then LOB_S.rem = 0
If LOB_S.max > 0, then LOB_S.rem = LOB_S.max - LOB_S.used

Set the Secondary Remaining Benefit (B_S.rem) equal to the Secondary Remaining Lifetime Ortho Benefit (LOB_S.rem).

B_S.rem = LOB_S.rem

For a non-orthodontic procedure, do the following:

Calculate the Secondary Remaining Annual Individual Benefit:

Terms
AIB_S.max	Secondary Maximum Annual Individual Benefit
AIB_S.used	Secondary Used Annual Individual Benefit
AIB_S.rem	Secondary Remaining Annual Individual Benefit

If AIB_S.max has no value, then AIB_S.rem = 9,999,999.99
If AIB_S.max = 0, then AIB_S.rem = 0
If AIB_S.max > 0, then AIB_S.rem = AIB_S.max - AIB_S.used

Calculate the Secondary Remaining Annual Family Benefit:

Terms
AFB_S.max	Secondary Maximum Annual Family Benefit
AFB_S.used	Secondary Used Annual Family Benefit
AFB_S.rem	Secondary Remaining Annual Family Benefit

If AFB_S.max has no value, then AFB_S.rem = 9,999,999.99
If AFB_S.max = 0, then AFB_S.rem = 0
If AFB_S.max > 0, then AFB_S.rem = AFB_S.max - AFB_S.used

Calculate the Secondary Remaining Benefit. Take the lesser of AIB_S.rem and AFB_S.rem, and then set B_S.rem equal to that lesser amount.

B_S.rem = min (AIB_S.rem ; AFB_S.rem)

Use the Secondary Remaining Benefit to adjust the Max Secondary Insurance Portion as needed.

Terms
I_S.max	Max Secondary Insurance Portion
B_S.rem	Secondary Remaining Benefit

Do one of the following:

If I_S.max<= B_S.rem, there is enough remaining benefit to cover the entire amount that is expected to be paid by the carrier. The Max Secondary Insurance Portion does not change.

I_S.max = I_S.max
If I_S.max > B_S.rem, the remaining benefits covers none or only a portion of the amount that is expected to be paid by the carrier. Set the Max Secondary Insurance Portion (I_S.max) equal to the Secondary Remaining Benefit (B_S.rem).

I_S.max = B_S.rem

Calculate the final amounts for the Total Insurance Portion, the Max Write-off, and the Max Patient Portion.

Terms
I_tot	Total Insurance Portion (for dual coverage)
I_P.max	Max Primary Insurance Portion
I_S.max	Max Secondary Insurance Portion
A_proc	Amount Charged (the procedure's Amount)
P_max	Max Patient Portion (for dual coverage)
W_max	Max Write-off (for dual coverage)

Do one of the following:

For either the Maintenance of Benefits or the Carve out/Non-duplication method of coordinating benefits, do the following:
1. Calculate the Total Insurance Portion. Add I_P.max and I_S.max, and then set I_tot equal to that sum.
  
  I_tot = sum (I_P.max + I_S.max)
2. Do one of the following:
  - If I_tot >= A_proc, do the following:
    - Set the Total Insurance Portion (I_tot) equal to A_proc.
      
      I_tot = A_proc
    - Set the Max Patient Portion (P_max) equal to zero.
      
      P_max = 0
    - Set the Max Write-off (W_max) equal to zero.
      
      W_max = 0
  - If I_tot < A_proc, do one of the following:
    - With the Insurance Sum (S) equal to I_tot + W_max, if S >= A_proc, do the following:
      1. Set the Max Patient Portion (P_max) equal to zero.
        
        P_max = 0
      2. Do one of the following:
        
        If S = A_proc, adjustments are not needed. The Max Write-off and the Total Insurance Portion stay the same.
        
        W_max = W_max
        
        I_tot = I_tot
        
        If S > A_proc, make adjustments in the following order (until S = A_proc):
        
        If S > A_proc, reduce W_max until S = A_proc or until W_max = 0, whichever comes first.
        
        If W_max = 0, and if S > A_proc, reduce I_tot (by reducing I_S.max) until S = A_proc.
    - With the Insurance Sum (S) equal to I_tot + W_max, if S < A_proc, do the following:
      - Calculate the Max Patient Portion. Subtract I_tot and W_max from A_proc, and then set P_max equal to that difference.
        
        P_max = A_proc - I_tot - W_max
      - The Max Write-off and the Total Insurance Portion stay the same.
        
        W_max = W_max
        
        I_tot = I_tot
For the Traditional method of coordinating benefits, do the following:
1. Calculate the Total Insurance Portion. Add I_P.max and I_S.max, and then set I_tot equal to that sum.
  
  I_tot = sum (I_P.max + I_S.max)
2. Calculate the Max Patient Portion. Subtract W_max, I_P.max, and I_S.max from A_proc, and then set P_max equal to that difference unless that difference is less than zero, in which case, set P_max equal to zero.
  
  P_max= max (0; A_proc - W_max - I_P.max - I_S.max)
3. Set the Sum of the Terms (s) equal to the sum of W_max, I_P.max, I_S.max, and P_max.
  
  S = sum (W_max + I_P.max + I_S.max + P_max)
4. Do one of the following:
  - If S = A_proc, adjustments are not needed. The Max Write-off and the Total Insurance Portion stay the same.
    
    W_max = W_max
    
    I_tot = I_tot
  - If S > A_proc, make adjustments in the following order (until S = A_proc):
    1. If S > A_proc, reduce P_max until S = A_proc or until P_max = 0, whichever comes first.
    2. If P_max = 0 and if S > A_proc, reduce W_max until S = A_proc or until W_max = 0, whichever comes first.
    3. If P_max = 0, if W_max = 0, and if S > A_proc, reduce I_tot (by reducing I_S.max) until S = A_proc.