Troubleshooting Insurance Estimates

This document provides troubleshooting steps to help ensure accurate insurance estimates. The commercial insurance plans that Dentrix Ascend supports are PPO (Preferred Provider Organization), DHMO (Dental Health Maintenance Organization), and indemnity.

Ledger

Procedure details

Click (or tap) a procedure on the patient's Ledger page, and then check the following details:

Bill to insurance

If this procedure should be billed to insurance, make sure that the Bill to insurance switch is set to On.
If this procedure should not be billed to insurance, make sure that the Bill to insurance switch is set to Off.

Insurance Estimate Overrides

Verify if the Automatically calculate insurance estimates switch is set to On. If it is set to Off, and there are incorrect estimates, change the Prim. ins portion, Sec. ins portion, and/or Ins write-off amounts.

Important: Turning off automatic insurance estimates has the following repercussions:

The benefit maximums and required deductibles are not used to calculate estimates for this procedure.
When changes that affect insurance estimates cause the Ins. est. update available flag to appear on the patient's Ledger, Patient Portion, or Guarantor Portion page, updating the estimates for unpaid procedures does not update the estimates for this procedure, so the estimates for it may need to be updated manually.
While using the Detailed View of the Patient Portion or Guarantor Portion page, a crossed-out calculator symbol appears next to the procedure to indicate that insurance estimates are not being calculated automatically, and the allowable amounts and coverage percentages do not appear.

Insurance Estimate Overrides

If this procedure is missing any Insurance Estimate Overrides, select the Primary and/or Secondary checkboxes, and then enter the Primary and/or Secondary amounts.
If this procedure has any incorrect Insurance Estimate Overrides, clear the Primary and/or Secondary checkboxes to remove the overrides, or edit the Primary and/or Secondary amounts.
If the Insurance Estimate Overrides are locked, if your user account has the rights to do so, click the Unlock icon to enter your credentials and then remove the overrides or edit the amounts if they are incorrect.

Date

Make sure that the procedure Date is the correct date of service.

Note: For the procedure to be eligible for insurance coverage, the date must be within the coverage period of the patient's insurance plan.

Amount

Make sure that the Amount is correct.
If the Amount has been overridden, click the Update to link to update the charge if it is incorrect.

Note: By default, the procedure Amount comes from the selected procedure on the selected provider's preferred fee schedule; however, if the selected procedure does not exist on that fee schedule, or the selected provider does not have a preferred fee schedule, the amount comes from the selected procedure on the location's procedure code list.

Provider

Make sure that the Provider is the correct rendering provider. The selected provider's preferred fee schedule is used to populate the Amount box by default. If the provider does not have a preferred fee schedule, the location's procedure code list is used.

Important: The rendering provider may be different from the billing provider, and it is the billing provider who must be contracted with the insurance carrier that administer the patient's insurance plan (PPO or DHMO plan only) for the insurance estimates to be calculated correctly.

Applied payments and credits

On the patient's Ledger page, check if any payments (patient or insurance) and credit adjustments are applied to the procedure.

Applied patient payments

Click (or tap) a patient payment. In the Edit Payment dialog box, see if the procedure is listed and has an Applied amount. If so, this affects the patient portion.

Applied credit adjustments

Click (or tap) a credit adjustment. In the Edit Credit Adjustment dialog box, see if the procedure is listed and has an Applied amount. If so, this affects the patient portion.

Applied insurance payments

Click (or tap) an insurance payment. In the Edit Payment dialog box, see if the procedure is listed and has an Applied amount. If so, this affects the insurance and patient portions.
On the patient's Ledger page, click (or tap) the amount in the Patient Portion box. On the Detailed View tab of the Patient Portion or Guarantor Portion page, click (or tap) a Charge Description to check if any payments (patient or insurance) and credit adjustments are applied to the procedure.

Patient's coverage

Insurance plan

Check the patient's insurance plan:

On the patient ribbon, if the patient has an active insurance plan, the Insurance icon is green; if not, it is gray. Click (or tap) the icon to view the patient's Insurance Information page.
If the desired plan is not listed, it may be expired. Set the Show Expired Plans switch to On to view all the patient's insurance plans.
If the desired plan is listed, make sure that the Insurance coordination order and Coverage Period are correct.
Do any of the following as needed:

Attach an insurance plan
1. On the patient's Insurance Information page, click (or tap) Add Plan.
  
  The options for entering insurance information become available.
2. Specify the Subscriber.
  Do one of the following:
  - If the patient is the subscriber for the plan that you are going to enter, leave his or her name in the Subscriber box.
  - If the patient is not the subscriber for the plan that you are going to enter, clear the name from the Subscriber box, begin typing part of the subscriber's name, continue typing as needed to narrow the results list, and then select a subscriber's name. The names of the insurance carrier and plan (or employer) that are attached to the selected subscriber appear automatically. (Skip step 3.)
3. If the patient is the subscriber, use the Plan Search box to search for and select an insurance plan.
  Do one of the following:
  - Select a plan by carrier, plan name, or group number:
    
    Select Search by Carrier/Plan/Employer.
    
    In the Plan Search box, begin typing a carrier name, an employer or a group plan name, or a group number. Continue typing as needed to narrow the results list. Then, select a plan.
  - Select a plan by patient:
    
    Select Search by Patient.
    
    In the Plan Search box, begin typing a patient name. Continue typing as needed to narrow the results list. Then, select the patient with the correct plan.
  - Add a new plan:
    
    If there are no results for the search criteria that you enter in the Plan Search box, click (or tap) Add New Carrier or Plan.
    
    The Add New Carrier or Plan dialog box appears.
    
    Do one of the following:
    
    Select an insurance carrier from the list of carriers that have already been added to your practice database.
    
    Add an insurance carrier to your organization's database:
    
    Click (or tap) Add Carrier.
    
    Note: Adding insurance carriers requires the "Create Carriers" security right.
    
    The Select carrier box becomes available.
    
    In the Select carrier box, begin typing the insurance carrier's name or payer ID. A list of supported insurance carriers appears. Continue typing as needed to narrow the search results.
    
    Important: Henry Schein One maintains a database of supported payers. The database is updated regularly, and a list of carriers and each carrier's details is sent to Dentrix Ascend. Selecting a carrier from the list of supported payers ensures that your practice has up-to-date information for that carrier. Also, using a supported payer allows you to add attachments to claims (however, the payer might not accept electronic attachments; in which case, you can mail the attachments separately from the claims or print and mail the claim and attachments together).
    
    Do one of the following:
    
    If the correct insurance carrier is listed, click (or tap) it to populate the boxes with that carrier's information.
    
    If the correct insurance carrier name is not listed, finish typing the full name. The name must start with a number or letter, not a special character).
    
    Then, press the Tab key, or click (or tap) outside the box. A message about adding unsupported payers appears.
    
    Click (or tap) Use New Carrier Name. The options for adding a new insurance carrier become available.
    
    Set up the other options as needed:
    
    Expected period of insurance claim resolution - The number of days after which you want to consider claims that are sent to the insurance carrier as being overdue. By default, the turnaround time is set to 14 days, but you can specify a different number of days to reflect the time frame that the carrier usually requires to process claims.
    
    Phone number - The insurance carrier's main contact phone number and extension (if applicable).
    
    Fax number - A fax number for the insurance carrier.
    
    Website - The insurance carrier's website address. Do not include "http://" or "https://" at the beginning of the website address.
    
    Notes:
    
    You cannot change the Carrier Name name after you click (or tap) Add.
    
    You cannot change the insurance carrier's Payer ID. The ID comes from a database (maintained by Henry Schein One) of payers that accept electronic claims, or if the payer is not supported, the ID is 06126 (in which case, the clearinghouse will have to print and mail a hard copy of the claim to the payer).
    
    You must save the insurance carrier's information to make the Available Procedures button available, so you can specify which procedures are available for posting to the records of patients who are covered by this carrier (when the "Carrier procedures" procedure filter is selected during posting).
    
    Click (or tap) Add.
    
    The options for adding a plan become available.
    
    Note: Adding plans to insurance carriers requires the "Create Insurance Plans" security right.
    
    Set up the following options:
    
    Plan/Employer Name - The name of the employer or insurance plan.
    
    Group # - The group plan number.
    
    Claim mailing address - The address where claims for the insurance plan are sent.
    
    Note: ZIP Codes must be nine digits.
    
    Phone - The insurance plan administrator's contact phone number and extension (if applicable).
    
    Fax Number - The fax number of the insurance plan administrator.
    
    Contact - The name of the insurance plan administrator.
    
    Email - The insurance plan administrator's email address.
    
    Benefit Renewal Month - The month that the insurance plan's benefits reset.
    
    Source of Payment - The type of insurance company that will remit payment: CHAMPUS, Blue Cross/Blue Shield, Commercial Insurance, Commercial Insurance (PPO), Commercial Insurance (DHMO), Medicare Part B, or Medicaid.
    
    Type - The plan covers dental or medical procedures.
    
    Max allowable amount fee schedule - The schedule of allowed charges for the insurance plan (PPO or DHMO plan only). The selected fee schedule will be used to determine a patient's portion and the recommended write-off.
    
    Important: For each provider (and each location that is set up as a billing provider for claims) who participates with this insurance plan, in that provider's user account (or that location's settings), you must select this carrier in the Contracted With section.
    
    You can also click (or tap) Max Allowable All Locations to open the Max Allowable Amount Fee Schedules By Location dialog box and set the max allowable fee schedule for the insurance plan by location. Access to this dialog box is available only if the Plan/Employer Name, Claim mailing address, City, State, ZIP Code, and Benefit renewal month have been entered.
    
    Coverage Table - The coverage table for the plan. Click (or tap) Coverage Table to open the Coverage Table for dialog box. Access to this dialog box is available only if the Plan/Employer Name, Claim mailing address, City, State, ZIP Code, and Benefit renewal month have been entered.
    
    For a coverage table that is based on insurance coverage percentages, change the default deductible type and/or coverage percentage for each procedure code range. For a coverage table that is based on fixed, patient copayments, change the default deductible type and/or copayment amount.
    
    Note: You can also add exceptions, which are used by Dentrix Ascend to automatically calculate insurance estimates.
    
    Payment Table - The payment table for the plan. Click (or tap) Payment Table to open the Payment Table dialog box. Access to this dialog box is available only if the Plan/Employer Name, Claim mailing address, City, State, ZIP Code, and Benefit renewal month have been entered.
    
    Manually add procedures in the plan's payment table as needed.
    
    Predeterminations - The procedures that require a predetermination (pre-authorization) under this plan. Click (or tap) Predeterminations to open the Manage Predeterminations dialog box. Access to this dialog box is available only if the Plan/Employer Name, Claim mailing address, City, State, ZIP Code, and Benefit renewal month have been entered.
    
    Do any of the following:
    
    Select checkboxes:
    
    To select the checkboxes of the listed procedures that commonly require a predetermination, click (or tap) Load Defaults. Be aware that doing this replaces the current selections.
    
    To select the checkboxes of the listed procedures according to the selections from another insurance plan, enter your search criteria (part of a carrier name, plan/employer name, or group number) in the Replace with box, continue typing as needed to narrow the results, and then select the correct plan. Be aware that doing this replaces the current selections.
    
    Manually select or clear the checkboxes of procedures in the list as needed.
    
    Note: To quickly locate a procedure, begin entering part of its code, description, or treatment area in the Search for procedure box. The procedures that match your search criteria are listed. Continue typing as needed to narrow the results.
    
    Set a charge threshold - To require a predetermination for any procedure that is not selected in the list but whose charge equals or exceeds a certain amount, select the Require predetermination for procedures over checkbox, and then enter an amount in the box provided.
    
    Copy selections to other plans - To copy this plan's selections to other plans that are associated with this plan's carrier, click (or tap) Distribute Settings. In the Distribute Predetermination Settings dialog box, select the checkboxes of the correct plans, and then click (or tap) Distribute & Save. Be aware that doing this replaces the current selections for the destination plans.
    
    Note - A note that is specific to this insurance plan. You can enter text, such as information from an EOB or other document from the insurance carrier. Also, you can insert a date if needed. The note is accessible from all patient records that have this insurance plan attached.
    
    Click (or tap) Save.
    
    To enter the required deductibles and maximum benefits for the plan, click (or tap) Benefits to open the Deductible and Benefits dialog box. Access to this dialog box is available only after you save the plan.
    
    Enter the required deductible amounts for each deductible type, enter the maximum benefits allowed, and then click (or tap) Save.
    
    Note: Adding required deductibles and maximum benefits to insurance plans requires the "Edit Benefits" security right.
    
    To specify the methods for handling the Coordination of Benefits (COB) between primary and secondary insurance claims for a patient with this insurance plan as his or her secondary plan, click (or tap) Coordination of Benefits to open the Coordination of Benefits for dialog box. Access to this dialog box is available only after you save the plan.
    
    For each Source of Payment for Primary Insurance Plan, select a Method for Coordination of Benefits, and then click (or tap) Save.
    
    Notes:
    
    If this insurance plan is attached to a patient's record as a secondary plan, the method being used for coordinating benefits appears on the patient's Insurance Information page when the options for the secondary plan are being displayed.
    
    Changing the coordination of benefits for insurance plans requires the "Edit Insurance Plans" security right.
    
    Click (or tap) Save.
4. Set up the rest of the options as needed, such as the subscriber ID, relation to the subscriber, coverage order, and coverage period.
  Set up the following options:
  - Subscriber ID # - The ID used to identify the subscriber of the insurance plan on claims that are submitted to the corresponding carrier. The subscriber ID might not be the same as the subscriber's Social Security Number.
    
    Note: When you save the plan, Dentrix Ascend attempts to verify with the carrier that the subscriber ID is valid. You may see a notification that the carrier does not accept real-time eligibility verification, the subscriber ID is invalid, or the subscriber ID could not be verified. These issues affect the patient's eligibility status for his or her appointments on the Insurance Eligibility page.
  - Release of Information - The subscriber authorizes the release of information to the practice. With this check box selected, "Signature on File" appears in box 36 on insurance claims. With this check box clear, box 36 is blank.
    
    Notes:
    
    For a subscriber, the default state of the Release of Information check box is determined by a certain insurance default.
    
    Selecting or clearing the Release of Information check box requires the "Edit Ins. Plan for Patient" and "Manage Subscriber Authorizations" security rights.
  - Assignment of Benefits - The subscriber authorizes payments from the carrier to go directly to the provider. With this check box selected, "Signature on File" appears in box 37 on insurance claims, and the carrier will send payments to your practice. With this check box clear, box 37 is blank, and the carrier will send payments to the subscriber.
    
    Notes:
    
    For a subscriber, the default state of the Assignment of Benefits check box is determined by a certain insurance default.
    
    Selecting or clearing the Assignment of Benefits check box requires the "Edit Ins. Plan for Patient" and "Manage Subscriber Authorizations" security rights.
  - Relation to Subscriber - For a subscriber, since he or she is the current patient, Self is selected automatically and cannot be changed. For a non-subscriber, select Spouse, Child, or Other.
  - Insurance coordination order - The coverage order of the plan (such as Primary or Secondary).
    
    Note: The positions that are available on the list are the positions in the coverage order that have active insurance plans, the positions in the coverage order that are missing insurance plans, and an additional position at the end of the coverage order.
  - Coverage Period - The date range that coverage under the plan is valid for the subscriber and his or her dependents. In the Coverage Start and Coverage End boxes, enter the date when coverage started and, if known, when it will end. For a non-subscriber, you can specify an end date that is before or the same as that of the subscriber.
    
    Note: For a secondary insurance plan, the start date cannot be earlier than the start date of the patient's primary insurance plan.
  - Eligibility - The patient's eligibility for coverage under the plan has been checked. If known, select the patient's eligibility status from the list: Unable to Verify, Eligible, or Ineligible. Then, enter today's date (or the date that eligibility was actually checked) in the Verification Date box.
    
    Note: Changing the eligibility status here affects the patient's eligibility status for his or her appointments on the Insurance Eligibility page and vice versa.
  - Note - Any notes regarding the insurance plan.
5. Click (or tap) Save.
6. To update the met deductibles and used benefits, click (or tap) Benefits. Access to the deductibles and benefits is available only after you save the plan in the patient's record.
  
  Note: Updating the met deductibles and used benefits requires the "Edit Ins. Benefits for Patient" security right.
Update an insurance plan
1. On the patient's Insurance Information page, select an insurance plan.
  
  The options for editing insurance information become available.
2. Update the information as needed, such as the subscriber ID, relation to the subscriber, coverage order, and coverage period.
  Set up the following options:
  - Subscriber and Plan - The subscriber and insurance associated with that subscriber. To change the subscriber and plan, click (or tap) in the Subscriber box, search for and select a different provider, and then select a plan. To change only the plan, select a different plan for the selected subscriber. To show or hide the plan selection list, click (or tap) the Show button or the Hide button .
  - Subscriber ID # - The ID used to identify the subscriber of the insurance plan on claims that are submitted to the corresponding carrier. The subscriber ID might not be the same as the subscriber's Social Security Number. Changing the ID will affect the subscriber and all patients covered under that subscriber.
    
    Note: When you save the plan, Dentrix Ascend attempts to verify with the carrier that the subscriber ID is valid. You may see a notification that the carrier does not accept real-time eligibility verification, the subscriber ID is invalid, or the subscriber ID could not be verified. These issues affect the patient's eligibility status for his or her appointments on the Insurance Eligibility page.
  - Release of Information - The subscriber authorizes the release of information to the practice. With this check box selected, "Signature on File" appears in box 36 on insurance claims. With this check box clear, box 36 is blank.
    
    Note: Selecting or clearing the Release of Information check box requires the "Manage Subscriber Authorizations" security right.
  - Assignment of Benefits - The subscriber authorizes payments from the carrier to go directly to the provider. With this check box selected, "Signature on File" appears in box 37 on insurance claims, and the carrier will send payments to your practice. With this check box clear, box 37 is blank, and the carrier will send payments to the subscriber.
    
    Note: Selecting or clearing the Assignment of Benefits check box requires the "Manage Subscriber Authorizations" security right.
  - Relation to Subscriber - For a subscriber, since he or she is the current patient, Self is selected automatically and cannot be changed. For a non-subscriber, select Spouse, Child, or Other.
  - Insurance coordination order - The coverage order of the plan (such as Primary or Secondary).
    
    Note: The positions that are available on the list are the positions in the coverage order that have active insurance plans and the positions in the coverage order that are missing insurance plans.
  - Coverage Period - In the Coverage Start and Coverage End boxes, enter the date that coverage started and, if known, the date that the coverage will end for the subscriber and all patients who are insured under the selected plan. For a non-subscriber, you can specify an end date that is before or the same as that of the subscriber.
    
    Notes:
    
    For a secondary insurance plan, the start date cannot be earlier than the start date of the patient's primary insurance plan.
    
    You cannot save a change in the coverage period if doing so would cause an outstanding claim not to be inside that coverage period. You must resolve the claim before you can change the coverage period.
  - Eligibility - If known, select the patient's eligibility status: Unable to Verify, Eligible, or Ineligible. Then, enter today's date (or the date that eligibility was actually checked) in the Verification Date box.
    
    Note: Changing the eligibility status here affects the patient's eligibility status for his or her appointments on the Insurance Eligibility page and vice versa.
  - Note - Any notes regarding the insurance plan.
3. Click (or tap) Save.

Note: For the procedure to be eligible for insurance coverage, the procedure date must be within the coverage period of a plan.

Payment table

Verify if the setting that allows payment tables to override coverage tables for insurance estimates is enabled or disabled. If it is enabled, verify that the payment table for the patient's insurance plan is set up correctly.

Enabling or disabling payment tables for insurance estimates

On the Settings menu, select Ledger Options.

The Ledger Options page opens.
Select the Ledger Rules tab.
Under Insurance Estimates & Write-Offs, set the Enable Payment Tables switch to one of the following statuses:
- Yes - Payment tables can be used for calculating insurance estimates in your organization.
  
  Notes:
  - If there is an override at the procedure level, that amount is used as the insurance portion instead of the amount in the payment table.
  - If the procedure exists in the payment table, that amount is used as the insurance portion.
  - The write-off for the remaining amount is based on the coverage table.
  - Whether or not payment tables are used, the insurance portion cannot exceed the procedure amount, the patient portion is equal to the procedure amount minus the sum of the insurance portion and the write-off amount, and estimates take used benefits and deductibles into account.
  - When you are viewing estimate details, if a payment table is in use for a procedure, that procedure’s amount is orange, and if you click the amount, a Payment Table In Use pop-up message appears for your reference.
- No - Payment tables do not affect insurance estimates.
  
  Note: A message appears in the payment tables of insurance plans to indicate that payment tables do not affect insurance estimates.
Click (or tap) Save.

Viewing and editing the payment table

On the patient's Insurance Information page, select an insurance plan.

The options for editing insurance information become available.
Click (or tap) the Plan link.

The Insurance Carriers page opens and displays the options for editing the insurance plan.
Click (or tap) Payment Table.

The Payment Table dialog box appears.

Notes:
- Initially, the plan's payment table is empty.
- Over time, as you update the payment table, the list may become long. To filter to list to show only procedures that match search criteria that you enter, in the Search by code/description box located above the list, begin typing a code or description.
Do any of the following as needed:
- To add procedures, do the following:
  1. Click Add Procedure to add a line item at the top of the list.
  2. In the Search box, begin typing part of a procedure code or description, and then select the correct procedure.
    
    The Amount box is selected automatically.
  3. Enter the amount that the payer pays for the selected procedure.
  4. Repeat steps a-c as needed to add other procedures.
  Note: As you add procedures, they are inserted before any existing procedures in the list. However, when you save the changes and then reopen the dialog box, the procedures are sorted by code.
- To remove a procedure, click the corresponding X.
- To edit a procedure's amount, click (or tap) in the corresponding Amount box, and then enter a new value.

Coverage table

Verify that the coverage table for the patient's insurance plan is set up correctly, and see if there are any exceptions for the procedure in that coverage table.

Viewing and editing the coverage table

On the patient's Insurance Information page, select an insurance plan.

The options for editing insurance information become available.
Click (or tap) the Plan link.

The Insurance Carriers page opens and displays the options for editing the insurance plan.
Click (or tap) Coverage Table.

The Coverage Table dialog box appears.

Insurance Coverage, %

Patient Copayment, $
Make sure the following are correct:
- Type: "Insurance Coverage, %" or "Patient Copayment, $"
- Code Range (for Insurance Coverage, %) or Procedure Code (for Patient Copayment, $)
- Deductible Type
- Coverage % (for Insurance Coverage, %) or Copayment $ (for Patient Copayment, $)
If necessary, you can change the type of coverage table. From the Type list, select either Insurance Coverage, % or Patient Copayment, $ to specify whether the coverage should be based on a percentage or a fixed amount, respectively.

Notes:
- If you change the type from Insurance Coverage, % to Patient Copayment, $, the coverage table changes to either the previous version of the patient copayment ($) type coverage table for this plan or, if this is the first time that you have changed the type, the default patient copayment ($) type coverage table.
- If you change the type from Patient Copayment, $ to Insurance Coverage, %, the coverage table changes to either the previous version of the insurance coverage (%) type coverage table for this plan or, if this is the first time that you have changed the type, the default insurance coverage (%) type coverage table.
If necessary, you can replace the coverage table with that of a template or another plan, or you can delete the coverage table to make a new one from scratch (not recommended).
Do one of the following:
- For an Insurance Coverage, % table, add, edit, and delete the procedure code ranges as needed.
  Do the following:
  1. Click (or tap) Add Range to add a procedure code range, or select an existing range to edit that range.
  2. Set up the following options for that range as needed:
    - Code Range - The ADA or custom procedure code range. These boxes accept dashes (-), periods (.), numbers, and letters, and they can be up to 10 characters in length. Make sure there are not any overlaps and gaps in the sequence between the starting and ending codes in the range and between other ranges.
      
      You can include an alias procedure codes in a range by typing a period (.) in either box. The Code Range boxes change to allow for entering suffixes. Enter a suffix in either or both suffix boxes. If you need a period in either of the main code boxes (the boxes to the left of the suffix boxes), you must type the period again in that box.
      
      Note: When you change a range and then click (or tap) somewhere else, the text of the range that you modified turns bold. Also, any ranges that overlap or that are invalid become highlighted in red, and you cannot save the changes to the coverage table until those errors are resolved.
    - Category - The procedure category for the procedures in the range.
    - Deductible Type - The type of deductible that the procedures in the range apply to.
    - Coverage % - The percent that the insurance carrier pays on covered charges (after any deductible, up to any allowed amount, and up to any maximum allowed benefit) for procedures in the range.
  3. Repeat the steps a - b for any other ranges that you want to add or edit.
  4. To delete a range, click (or tap) the corresponding Remove button , and then click (or tap) Delete on the confirmation message that appears.
    
    Important: If you are deleting the only range in the coverage table, the entire table will be deleted.
- For a Patient Copayment, $ table, add, edit, and delete the procedure codes as needed.
  Do the following:
  1. To add procedures codes, do the following:
    1. Click (or tap) Add Procedure.
      
      The Add Procedures dialog box appears.
    2. Select the check boxes of the procedure codes that you want to add to the coverage table. You can select or deselect the check box in the column header to select and deselect all the procedure codes at the same time.
    3. Click (or tap) Add Checked.
      
      Note: If you are adding procedure codes to a coverage table that already has procedure codes, the procedure codes are added at the top of the table, which might not be the correct order; however, when you save the template, the procedure codes will be listed in the correct order.
  2. To edit an existing or newly-added procedure code, select it.
  3. Set up the following options for that code as needed:
    - Deductible Type - The type of deductible that the procedure applies to.
    - Copayment $ - The patient co-pay. Patients will pay the specified amount for the procedure.
  4. Repeat the steps a - c for any other codes that you want to add or edit.
  5. To delete a code, click (or tap) the corresponding Remove button , and then click (or tap) Delete on the confirmation message that appears.
    
    Important: If you are deleting the only code in the coverage table, the entire table will be deleted.
To add, edit, or delete exceptions to the coverage for specific procedures, click (or tap) Manage Exceptions.
Do one of the following:
- To apply the changes to the coverage table and create a new coverage table template using the specified coverage options, click (or tap) Save As New Template. In the New Coverage Table Template dialog box that appears, enter a name for the template, and then click (or tap) Save.
- To apply the changes to the coverage table, click (or tap) Save.
Click (or tap) Save or Cancel.

Viewing and editing exceptions in the coverage table

On the patient's Insurance Information page, select an insurance plan.

The options for editing insurance information become available.
Click (or tap) the Plan link.

The Insurance Carriers page opens, and displays the options for editing the insurance plan.
Click (or tap) Coverage Table.

The Coverage Table dialog box appears.

Insurance Coverage, %

Patient Copayment, $
Click (or tap) Manage Exceptions.

The Manage Exceptions dialog box appears.
In the Exceptions list, expand a Code to view the corresponding exceptions, and then select an exception.

Notes:
- To search for a procedure code, begin entering a code in the Search for a procedure by code box, and continue typing as needed to narrow the list.
- If at least one Code is expanded, to quickly collapse them all, click (or tap) Collapse All. If they are all collapsed, to expand them all, click (or tap) Expand All.
The Edit Exception dialog box appears.
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 check boxes 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 check boxes, select or clear the check box in the header at the top of the list.
      
      To quickly select or clear a range of check boxes, click (or tap) the first check box of the desired range, and then, while pressing the Shift key, click (or tap) the last check box 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 check boxes 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 check boxes, select or clear the check box in the header at the top of the list.
      
      To quickly select or clear a range of check boxes, click (or tap) the first check box of the desired range, and then, while pressing the Shift key, click (or tap) the last check box 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 check box, and then select the correct type of deductible from the corresponding list.
      
      Note: The Deductible Type check box 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.
Click (or tap) Done.

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

Viewing coverage exceptions from the Ledger

On the patient's Ledger page, click (or tap) the amount in the Patient Portion box.
On the Detailed View tab of the Patient Portion or Guarantor Portion page, check for coverage exceptions in the following columns:
- Primary Coverage, % - The percent covered according to the primary insurance plan's coverage table. If the percent is a link, you can click (or tap) it to view the applicable coverage exception.
- Primary Copayment, $ - The copay according to the primary insurance plan's coverage table. If the amount is a link, you can click (or tap) it to view the applicable coverage exception.
- Secondary Coverage, % - The percent covered according to the secondary insurance plan's coverage table. If the percent is a link, you can click (or tap) it to view the applicable coverage exception.
- Secondary Copayment, $ - The copay according to the secondary insurance plan's coverage table. If the amount is a link, you can click (or tap) it to view the applicable coverage exception.

Deductibles and Benefits

Check the deductibles (required and met) and benefits (maximum and used) of the patient's insurance plan.

Viewing and editing the required deductibles and maximum benefits

On the patient's Insurance Information page, select an insurance plan.

The options for editing insurance information become available.
Click (or tap) the Plan link.

The Insurance Carriers page opens, and displays the options for editing the insurance plan.
Click (or tap) Benefits.

The Deductibles and Benefits dialog box appears.
Change the deductibles and benefits of the plan as needed.

Note: Currently Dentrix Ascend calculates the deductible for each category. If there is only one deductible, enter the amount of the deductible in the Preventive, Basic, or Major box in each column (Annual Individual, Annual Family, and Lifetime Individual) as applicable unless preventive procedures do not require a deductible; in which case, enter the amount of the deductible in the Basic or Major box in each column as applicable. This will prevent Dentrix Ascend from calculating the deductible twice for a procedure, and it won't matter which type of procedure you post first. Additionally, you must update the coverage table for the plan. Make sure that all procedures, except for preventive procedures if they do not require a deductible, are associated with the deductible type that you entered an amount for.
Click (or tap) Save.

Viewing and editing the met deductibles and used benefits

On the patient's Insurance Information page, select an insurance plan.

The options for editing insurance information become available.
Click (or tap) Benefits.

The Deductibles and Benefits dialog box appears.
As needed, for the Current Year and/or Previous Year, enter or change any Met amounts for Deductibles and/or Used amounts for Benefits.
Click (or tap) Save.

Viewing remaining deductibles and benefits from the Ledger

On the patient's Ledger page, click (or tap) the amount in the Patient Portion box.
On the Detailed View tab of the Patient Portion or Guarantor Portion page, view the calculated remaining deductibles and benefits in the following columns:
- Primary Deductibles Remaining - The unmet portion of the primary insurance plan's deductible that is to be paid by the patient.
- Primary Insurance Portion Remaining - The estimated primary insurance portion. If the amount is a link, you can click (or tap) it to view the remaining primary plan benefits prior to the primary insurance carrier paying for the charge but after what is expected to be paid by the primary insurance carrier for any outstanding charges listed before this charge.
- Secondary Deductibles Remaining - The unmet portion of the secondary insurance plan's deductible that is to be paid by the patient.
- Secondary Insurance Portion Remaining - The estimated secondary insurance portion. If the amount is a link, you can click (or tap) it to view the remaining secondary plan benefits prior to the secondary insurance carrier paying for the charge but after what is expected to be paid by the secondary insurance carrier for any outstanding charges listed before this charge.

Insurance Defaults

Billing provider

Important: The rendering provider may be different from the billing provider. For the insurance estimates to be calculated correctly, the billing provider must be contracted with the insurance carrier that provides the patient's insurance plan (PPO or DHMO plan only).

Verify the billing provider:

If you are not already viewing the correct location, select it on the Location menu.
On the Settings menu, under Production, click (or tap) Insurance Defaults.

The Insurance Defaults page opens.
Set up the following option:
- Billing Provider - By default, services will be billed to an insurance plan on behalf of a specific provider (select one), a location in your organization or a business entity (select one, if set up as a billing provider), or the provider who performed the procedures. If you select Provider of Procedures, to handle cases where the provider of a procedure is a secondary provider (for example, a hygienist), make sure that you select the primary provider, location, or entity that you want to use as the alternate billing provider. Only providers who have access to the current location are available.
  
  With the Warn when scheduling an appointment if the Billing Provider is not contracted with the patient's primary insurance plan switch set to On, a warning symbol and an accompanying message can appear in the following areas of Dentrix Ascend:
  - Next to the primary insurance plan on a patient's Insurance Information page if the patient's primary provider is not contracted with the patient's primary insurance plan.
  - Next to the patient's name on a patient's Appointment Information panel if the appointment provider for a patient's appointment is not contracted with the patient's primary insurance plan.
Click (or tap) Save.

Provider

Fees

If the billing provider is a user, verify if the provider is contracted with the carrier

Do the following to verify the provider's contract status:

On the Settings menu, under Location, click (or tap) User Accounts.

The User Accounts page opens.
On the User Accounts page, select the billing provider's user account.

The options for editing the user account become available.
On the Fees tab, under Contracted With, as needed, expand the section that corresponds to the first letter or number that the carrier's name starts with (for example, A, D, and P), and then verify if the checkbox next to that carrier is selected.
Select or clear the checkbox as needed.
Click (or tap) Save.

Verify if the rendering provider has a preferred fee schedule

On the Settings menu, under Location, click (or tap) User Accounts.

The User Accounts page opens.
On the User Accounts page, select the rendering provider's user account.

The options for editing the user account become available.
On the Fees tab, verify if a fee schedule is selected in the Fee Schedules list, and if so, if it is the correct one.
Select or change the fee schedule as needed.
Click (or tap) Save.

Location

Fees

If the billing provider is a location (or entity), verify if the location is contracted with the carrier

Do the following to verify the location's contract status:

If you are not already viewing the correct location, select it on the Location menu.
On the Settings menu, under Location, click (or tap) Location Information.

The Location Information page opens.
On the Claim Provider tab, for Contracted With, as needed, expand the section that corresponds to the first letter or number that the carrier's name starts with (for example, A, D, and P), and then verify if the checkbox next to that carrier is selected.

Note: The Claim Provider tab is available only if the Use this location as a claim provider for insurance switch is set to Yes.
Select or clear the checkbox as needed.
Click (or tap) Save.

Verify the location's preferred fee schedule

If you are not already viewing the correct location, select it on the Location menu.
On the Settings menu, under Location, click (or tap) Location Information.

The Location Information page opens.
Verify that the correct fee schedule is selected in the Preferred fee schedule list.
Click (or tap) Save.

Insurance plan

Contracted fee schedule and coordination of benefits

On the patient's Insurance Information page, select an insurance plan.

The options for editing insurance information become available.
Click (or tap) the Plan link.

The Insurance Carriers page opens, and displays the options for editing the insurance plan.
Set up the following options:
- Source of Payment - The type of insurance company that will remit payment: CHAMPUS, Blue Cross/Blue Shield, Commercial Insurance, Commercial Insurance (PPO), Commercial Insurance (DHMO), Medicare Part B, or Medicaid.
- Max allowable amount fee schedule - The schedule of allowed charges for the insurance plan (PPO or DHMO plan only). The selected fee schedule will be used to determine a patient's portion and the recommended write-off.
  
  Important: For each provider (and each location that is set up as a billing provider for claims) who participates with this insurance plan, in that provider's user account (or that location's settings), you must select this carrier in the Contracted With section.
  
  You can also click (or tap) Max Allowable All Locations to open the Max Allowable Amount Fee Schedules By Location dialog box and set the max allowable fee schedule for the insurance plan by location.
- Coordination of Benefits - The methods for handling the Coordination of Benefits (COB) between primary and secondary insurance claims for a patient with this insurance plan as his or her secondary plan. Click (or tap) Coordination of Benefits to open the Coordination of Benefits for dialog box.
  
  For each Source of Payment for Primary Insurance Plan, select a Method for Coordination of Benefits, and then click (or tap) Save.
  
  Notes:
  - If this insurance plan is attached to a patient's record as a secondary plan, the method being used for coordinating benefits appears on the patient's Insurance Information page when the options for the secondary plan are being displayed.
  - For more information about the coordination of benefits, refer to the topic about Coordination of benefits.
  - Changing the coordination of benefits for insurance plans requires the "Edit Insurance Plans" security right.
Click (or tap) Save.

Viewing contracted fees from the Ledger

On the patient's Ledger page, click (or tap) the amount in the Patient Portion box.
On the Detailed View tab of the Patient Portion or Guarantor Portion page, check for contracted fees in the following columns:
- Primary Allowable Amount - The contracted amount according to the primary insurance plan's fee schedule.
- Secondary Allowable Amount - The contracted amount according to the secondary insurance plan's fee schedule.

Fee schedules

Hierarchy

Note: The procedure Amount comes from the rendering provider's preferred fee schedule unless the provider does not have one, in which case, the amount comes from the location's preferred fee schedule.

Verify the procedure amount in any of the following fee schedules:

The insurance plan's Max allowable amount fee schedule
The rendering provider's preferred Fee Schedule
The location's Preferred fee schedule

Viewing and editing fee schedules

On the Settings menu, under Production, click (or tap) Fee Schedules.

The Fee Schedules page opens.

Note: To search for a fee schedule, begin typing part of the name of a fee schedule in the Search for Fee Schedule box, and continue typing as needed to narrow down the list.
Select a fee schedule.

The options for editing the fee schedule become available.
If the fee schedule has multiple versions, select the version that you want to update from the Fee schedule version list. This list is available only if the fee schedule has multiple versions.
Do any of the following as needed:
- Change the name of the fee schedule in the Name of fee schedule box.
- To set the end date for the fee schedule and make a new version of the fee schedule that will become effective after the specified date, do the following:
  1. Click (or tap) Set End Date.
    
    The Set End Date for This Version of the Fee Schedule dialog box appears.
  2. If this is not the first version of the fee schedule, specify the Start date. This box is available only if there is an existing previous version. Changing the start date affects the end date of the previous version.
  3. Specify the End date. The next version will become effective on the day after the specified end date for this version. If there is an existing next version, changing the end date for this version affects the start date of the next version.
  4. Click (or tap) Set & Save. Ignore step 5 unless you are going to make changes to the fees of any version of the fee schedule.
  Notes regarding multiple versions:
  - A procedure with an Other status uses the version of a fee schedule that is effective on the date of the appointment. This affects scheduled production.
  - A procedure with a Tx Plan status uses the version of a fee schedule that is effective on the date of the procedure. This affects scheduled production if the procedure is attached to an appointment.
  - An insurance estimate is determined from the version of a fee schedule that is effective on the service date of the procedure for which the calculation is being made.
  - A write-off is determined from the version of a fee schedule that is effective on the service date of the procedure for which the calculation is being made.
  - The day sheet, aged receivables, and outstanding claims reports determine production from the versions of fee schedules that are effective on the service dates of the procedures being reported on.
- Optionally, to import fees from a .csv file, on the Bulk Edit menu, select Import fees from file.
- To increase or decrease all the fees in the fee schedule by the same amount or percentage, do the following:
  1. On the Bulk Edit menu, select Increase all by.
    
    The Bulk Edit - Increase All dialog box appears.
  2. Enter a positive or negative number (for example, 20 or -20), and then select $ or %.
  3. Select the Round up resulting values to the nearest dollar checkbox if you want to round up the new fees.
  4. If you are increasing fees, to ignore any current fees with a $0.00 amount (they will stay at $0.00; only non-zero fees will be increased), select the Exclude $0.00 fees from increase checkbox.
  5. Click (or tap) Proceed. The resulting fees appear in the New Fee column.
- For each procedure, do any of the following as needed:
  - Enter or change the fee that you charge as needed in the corresponding box in the New Fee column.
    
    Note: If this fee schedule is the location's preferred fee schedule, changing the fee of a procedure code here affects the fee for the same procedure code on the location's Procedure Codes page and vice versa.
  - If you do not want to allow an automatic write-off to be posted, select the corresponding checkbox in the No Write-off column.
    
    Notes:
    - With the No Write-off checkbox selected for procedures, a write-off can occur only if this fee schedule is selected as the Max allowable amount fee schedule for a patient's insurance plan. Also, a write-off cannot occur if a patient's record has a discount plan attached and no insurance coverage is attached.
    - To select or clear every procedure's checkbox at the same time, select or clear the checkbox at the top of the column.
    - To select the checkboxes of a range of adjacent procedures, select the first checkbox of the range, and then while holding the Shift key, select the last checkbox of the range. All the checkboxes from the first one to the last one are selected.
  Tips:
  - To search for a procedure, begin typing a code or description in the Search by code/description box, and continue typing as needed to narrow down the list of procedures.
  - The Hide inactive procedures checkbox is selected by default, so only active procedures are shown. To temporarily show inactive procedures too, clear this checkbox (the checkbox reverts back to being selected the next time you access the Fee Schedules page and select a fee schedule).
Click (or tap) Save.

Calculations

Insurance estimates

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.

Troubleshooting Insurance Estimates

Ledger

Procedure details

Bill to insurance

Insurance Estimate Overrides

Insurance Estimate Overrides

Date

Amount

Provider

Applied payments and credits

Applied patient payments

Applied credit adjustments

Applied insurance payments

Patient's coverage

Insurance plan

Attach an insurance plan

Update an insurance plan

Payment table

Enabling or disabling payment tables for insurance estimates

Viewing and editing the payment table

Coverage table

Viewing and editing the coverage table

Viewing and editing exceptions in the coverage table

Viewing coverage exceptions from the Ledger

Deductibles and Benefits

Viewing and editing the required deductibles and maximum benefits

Viewing and editing the met deductibles and used benefits

Viewing remaining deductibles and benefits from the Ledger

Insurance Defaults

Billing provider

Provider

Fees

If the billing provider is a user, verify if the provider is contracted with the carrier

Verify if the rendering provider has a preferred fee schedule

Location

Fees

If the billing provider is a location (or entity), verify if the location is contracted with the carrier

Verify the location's preferred fee schedule

Insurance plan

Contracted fee schedule and coordination of benefits

Viewing contracted fees from the Ledger

Fee schedules

Hierarchy

Viewing and editing fee schedules

Calculations

Insurance estimates

Understanding how insurance estimates are calculated