Troubleshooting Insurance Estimates

Write-offs:

• Automatically post contracted write-offs when claims are created - Calculate the write-off; post the write-off automatically when a claim is created.

• Manually post contracted write-off during claim adjudication - Calculate the write-off; do not post the write-off automatically when a claim is created.

• No write-off. Post contracted fee, if applicable - Do not calculate the write-off.

Enable Payment Tables - Override the coverage percentage if the posted/charted procedure exists in the plan's payment table.

PPO Write-offs or Contracted Amounts - Use the Billing Provider or Rendering Provider.

Billing Provider:

• Specific Provider - Specify the primary provider or the location.

• Provider of Procedures - Specify the primary or secondary provider.

  • To handle cases where the provider of procedure is not an active Primary Provider, select an alternate Billing Provider - Specify the primary provider or the location.

Rendering Provider:

• Specific Provider - Specify the primary provider.

• Provider of Procedures - Specify the primary or secondary provider.

  • Use the patient's primary provider if the provider of procedures is not an active Primary Provider:

    • With checkbox clear, for To handle cases where the provider of procedures is not an active Primary Provider, select an alternate Rendering Provider, specify the primary provider.

    • With checkbox selected, for To handle cases where the patient has no Primary Provider or provider of procedures is not an active Primary Provider, select an alternate Rendering Provider, specify the primary provider.

Code - The code is relevant for coverage tables, payment tables, fee schedules, and when the procedure is posted/charted.

Location Fee - The fee in the location's preferred fee schedule. (The fee can vary by location.)

Bill to insurance - This switch determines the default state of the switch when the procedure is posted/charted. (This is an organization-level setting.)

Preferred fee schedule - The location's preferred fee schedule is used for PPO write-offs or contracted amounts if the location is the billing/rendering provider according to the insurance defaults.

Use this location as a claim provider for insurance:

• Claim Provider tab > Contracted with - The carriers that the location is contracted with. This is relevant if the location is the billing/rendering provider according to the insurance defaults.

• Claim Provider tab > Post UCR for Maxed Patients - The carriers that allow you to charge your UCR fee when the patient's annual maximum benefit has been reached.

Fee Schedule - The provider's assigned fee schedule is used for PPO write-offs or contracted amounts if the provider is the billing/rendering provider according to insurance defaults.

Contracted with - The carriers that the provider is contracted with. This is relevant if the provider is the billing/rendering provider according to the insurance defaults.

Paid in Full Enabled - If this is selected, a Paid in Full column is available.

Current Fee - The amount to charge.

No Write-off - An automatic write-off will be posted for the procedure unless this fee schedule is the plan's contracted fee schedule. (This option is available only if not posting contracted fees; and can be selected only if Paid in Full is not selected.)

Paid in Full (available only if Paid in Full Enabled is selected; and can be selected only if No Write-off is not selected) - Instead of the patient being responsible for a portion of the charge, anything over the maximum allowed (contracted) rate gets written off.

Post UCR Fee - The UCR fee will be posted instead of the contracted (max allowed) fee. (This option is available only if posting contracted fees.)

Max allowable amount fee schedule - The fee schedule for determining contracted (max allowed) amounts.

Max Allowable Amount Fee Schedules By Location - The contracted fee schedules can be set per location.

Coverage Table:

• By coverage percentage:

  • Code Range.

  • Deductible Type.

  • Coverage %.

  • Exception - Not covered, frequency, shared frequency, downgrade, or age limitation. (Currently, waiting period is ignored for automatic insurance calculations.)

• By patient copayment:

  • Code.

  • Deductible Type.

  • Copayment $.

  • Exception - Currently, exceptions are ignored for automatic insurance calculations.

Benefits:

• Deductibles:

  • Annual Individual Required - Preventive, Basic, Major, or Ortho.

  • Annual Family Required - Preventive, Basic, or Major.

  • Lifetime Individual Required - Preventive, Basic, or Major.

• Benefits:

  • Annual Individual Maximum.

  • Annual Family Maximum.

  • Lifetime Ortho Maximum.

Payment Table:

• Code.

• Amount.

Source of payment - The type of insurance company (such as commercial or Medicaid).

Coordination of Benefits:

• Source of Payment for Primary Insurance Plan - The type of primary insurance company.

• Method for Coordination of Benefits - The method for handling the Coordination of Benefits (COB) between the primary and secondary insurance claims: Traditional, Maintenance of benefits, or Carve Out/Non Duplication.

Location - The place of service depends on the location that was logged in to when the procedure was posted/charted. The location is relevant for knowing which location's insurance defaults to use. Also, the location can affect which location's preferred fee schedule to use.

Transaction date - The date of service must be within plan's coverage period. Also, the date is relevant if a frequency coverage exception applies.

Provider - The provider can affect the amount being charged.

Procedure - The procedure is relevant for the coverage table, payment table, and fee schedule. Also, the procedure can be downgraded to another procedure if a downgrade coverage exception applies.

Bill to insurance - This switch determines whether the procedure should be billed to insurance or not. (The default state of this switch can be changed for this procedure code (an organization-level setting).

Amount:

• If not posting contracted fees using rendering/billing provider - The amount comes from the provider's fee schedule if one is assigned; otherwise, the amount comes from the location's preferred fee schedule.

• If posting contracted fees using rendering/billing provider - If the rendering/billing provider according to insurance defaults is contracted with the carrier, the amount comes from plan's max allowed fee; otherwise, the amount comes from the location's preferred fee schedule. The amount may need to be updated (if it does not match the applicable fee schedule).

UCR fee - The amount comes from the provider's fee schedule if one is assigned; otherwise, the amount comes from the location's preferred fee schedule. This amount is billed to insurance on claims. (This option is available only if posting contracted fees using rendering/billing provider.)

Tooth, Surfaces, etc. - The treatment area is relevant if a frequency coverage exception applies.

Insurance Estimates tab:

• Outstanding Insurance Estimates:

  • Automatically calculate insurance estimates - If this switch is off, make sure that the estimates are correct, or turn the switch on to have the estimates calculated automatically.

  • Prim. ins portion - The estimated primary insurance portion.

  • Sec. ins portion - The estimated secondary insurance portion (if the patient has secondary coverage).

  • Ins write-off - The estimated write-off.

  • Guar. Portion - The estimated guarantor portion.

• Insurance Estimates Overrides:

  • Primary - The amount to use for the primary insurance's portion.

  • Secondary - The amount to use for the secondary insurance's portion (if the patient has secondary coverage).

Birth date - The patient's birth date is relevant if an age limitation coverage exception applies.

Primary provider - The provider is relevant if needed to determine the rendering provider (for PPO write-offs or contracted amounts).

None.

Basic (uninsured):

• Select a fee schedule.

• Discount plan expiration.

Sliding fees:

• Patient pays per visit.

Order - Primary, secondary, or so forth.

Coverage Period - The date of service must be within the plan's coverage period.

Coverage table.

Benefits:

• Deductibles:

  • Annual Individual Met - Preventive, Basic, Major, or Ortho.

  • Annual Family Met - Preventive, Basic, or Major.

  • Lifetime Individual Met - Preventive, Basic, or Major.

• Benefits:

  • Annual Individual Used.

  • Annual Family Used.

  • Lifetime Ortho Used.

  • Annual Individual Implant - Maximum (read only) or Used.

  • Lifetime Individual Implant - Maximum (read only) or Used.