Working with Coverage Tables and Coordination of Benefits

This document provides instructions for creating coverage table templates and adding exceptions in coverage, updating insurance plans, editing coverage tables and exceptions in coverage for insurance plans in Dentrix Ascend. This document also provides an explanation of how Dentrix Ascend calculates insurance estimates.

1. Coverage table templates

Creating coverage table templates

Dentrix Ascend provides two default templates (which are named "All Procedures") and allows you to create various templates that you can use in your organization for setting up the coverage tables of insurance plans.

Note: Coverage table templates are global (available to all locations across your organization).

To create a coverage table template

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

    The Coverage Table Setup page opens.

  2. On the Coverage Table Setup page, do one of the following:

    • Create new - To make an all new coverage table template, click (or tap) New Coverage Table.

    • Base on existing - To make a coverage table template based on an existing template, select the template that is similar to the one that you want to create.

      Note: The templates are grouped by type. Expand Insurance Coverage, % to view templates that are based on insurance coverage percentages, or expand Patient Copayment, $ to view templates that are based on fixed, patient copayments.

    The options for adding or editing the coverage table template appear. The options that are available depend on whether you are creating a new template or making one that is based on an existing template and whether the template is based on insurance coverage percentages or fixed, patient copayments.

    New

    Based on Existing

    Insurance Coverage, %

    Patient Copayment, $

  3. Enter or change the Template name. The name must be unique relative to the templates of the same type (Insurance Coverage, % or Patient Copayment, $).

  4. If you are creating a new template, 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. Once you save the template, you cannot change the type.

    With a Type selected, the options for creating the template become available.

    Insurance Coverage, %

    Patient Copayment, $

  5. Do one of the following:

    • For an Insurance Coverage, % template, 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 template will be deleted. However, you cannot delete all the ranges in the default template (which is named "All Procedures").

    • For a Patient Copayment, $ template, 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 template will be deleted. However, you cannot delete all the codes in the default template (which is named "All Procedures").

  6. To add, edit, or delete exceptions to the coverage for specific procedures, click (or tap) Manage Exceptions.

  7. Do one of the following:

    • For an all new template, click (or tap) Create.

    • For a template based on another, click (or tap) Save As New Template.

Adding exceptions in coverage table templates

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

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

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

To add an exception

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

    The Coverage Table Setup page opens.

  2. Select a coverage table template.

    The options for editing the coverage table appear.

    Insurance Coverage, %

    Patient Copayment, $

  3. Click (or tap) Manage Exceptions.

    The Exceptions dialog box appears.

  4. Click (or tap) Add New Exception.

    The options for adding the exception become available.

  5. Select one or multiple procedure codes, and set up the other options on the following tabs as needed:

    • Exception Type

      1. Do one of the following:

        • To add multiple procedures that are not covered, do the following:

          1. Leave Not covered selected as the Exception type.

          2. Click (or tap) Add Bulk Procedures.

            The tab now displays a list of procedure codes.

          3. Select the check boxes that correspond to the procedure codes that are not covered. To search for a procedure, begin typing the code or its description in the Procedure code(s) search box, continue typing as needed to narrow down the procedure code list.

            Note: After searching for and selecting a procedure, to return to viewing the entire procedure code list, delete the search text from the Procedure code(s) search box.

        • To add one procedure code for any exception type, set up the following options:

          • Procedure code - To select a procedure, begin typing the code or its description, continue typing as needed to narrow the results, and then select a code.

          • Exception type - Select one of the following options: Not covered, Downgrade, or Coverage with age limit.

          • Pre-estimate - If the insurance carrier requires that a pre-treatment estimate (pre-authorization) be submitted before treatment can begin for this procedure, select the Required check 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 Downgrade exception type, begin typing the code or description of the substitute procedure to Downgrade coverage to, continue typing as needed to narrow the results, and then select the code.

        • For a Coverage with age limit exception type, set up the following options:

          • Deductible Type - Select the type of deductible that the patient must pay for this procedure.

          • Coverage, % - Enter the percentage of the fee charged that the insurance carrier covers for this procedure. This option is available only for coverage tables that are based on insurance coverage percentages.

          • Copayment, $ - Enter the co-pay that the patient pays for this procedure. This option is available only for coverage tables that are based on fixed, patient copayments.

          • Max age limit - Enter an age limit to specify that the insurance carrier covers this procedure for patients who are of the specified age or younger.

          Insurance Coverage, %

          Patient Copayment, $

      2. Click (or tap) Next.

    • Reason for Exception

      Enter the reason for the exception in coverage for this procedure.

  6. Click (or tap) Done. (This button is available only if the Reason for Exception tab is selected.)

2. Insurance plans

Updating insurance plan information

You can update the information for an insurance plan attached to an insurance carrier that was added to your organization's database. Any changes made to a plan's information affects all patients covered by that plan.

To update an insurance plan

  1. On the Home menu, under Insurance, click (or tap) Carriers.

    The Insurance Carriers page opens.

  2. On the Insurance Carriers page, select an insurance carrier.

    Tip: To help you locate an insurance carrier quickly, in the Filter box, enter part or all of a carrier's name, plan/employer, or group number to filter the carrier list so that it displays only those carriers that match what you enter.

    The options to edit the insurance carrier become available.

  3. Under Plans/Employers, select an insurance plan.

    Tip: To help you locate a plan quickly, in the Filter box, enter part or all of the plan/employer name or group number to filter the plan list so that it displays only those plans that match what you enter.

    The options for editing the insurance plan become available.

  4. Change the plan information, such as the name or address, as needed.

    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 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.

      Note: Patients whose insurance plans have "Medicaid" as the Source of Payment will not receive billing statements, as it is illegal in many states to send billing statements to Medicaid patients.

    • 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.

    • Coverage Table - The coverage table for the plan. For a coverage table that is based on insurance coverage percentages, you can change the default deductible type and coverage percentage for each procedure code range. For a coverage table that is based on fixed, patient copayments, you can change the default deductible type and copayment amount. Access to this dialog box is available only if the Plan/Employer Name, Claim mailing address, and Benefit renewal month have been entered.

      Note: You can also add, edit, or delete exceptions to the coverage for specific procedures.

    • Benefits - The deductibles and benefits for the plan. You can enter the required deductible amounts for each deductible type and enter the maximum benefits allowed. Access to this dialog box is available only if a Plan/Employer Name, Address, City, State, and ZIP Code have been entered.

    • 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) the button to open the Coordination of Benefits dialog box. For each Source of Payment for Primary Insurance Plan, select a Method for Coordination of Benefits, and then click (or tap) Save.

      Note: 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.

    • 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.

  5. Click (or tap) Save.

Editing coverage tables

You can edit the coverage table that is attached to a patient's insurance plan. You can edit the coverage table that is attached to an insurance plan. A coverage table references what procedures a carrier covers and at what percentage. Along with deductibles and benefits, a coverage table allows for accurate insurance estimates.

Tip: You can also replace the coverage table of any given insurance plan with the coverage table from any other plan or from a coverage table template.

Important: Changing an insurance plan's coverage table affects all patients covered by that insurance plan.

To edit a coverage table

  1. If the correct patient is not already selected, use the Patient Search box to access the patient's record.

    Note: You can include inactive patients in the search results by setting the Include inactive patients switch to On.

  2. Do one of the following:

    • On the Patient menu, under General, click (or tap) Overview. The patient's Overview page opens. In the Insurance box, click (or tap) an insurance Plan link.

    • On the Patient menu, under Insurance, click (or tap) Insurance Information. The patient's Insurance Information page opens. Click (or tap) an insurance plan.

    The options for editing insurance information become available.

  3. While viewing an insurance plan that is attached to a patient's record, click (or tap) Coverage Table.

    The Coverage Table dialog box appears.

    Insurance Coverage, %

    Patient Copayment, $

  4. 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.

  5. 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).

  6. 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.

  7. To add, edit, or delete exceptions to the coverage for specific procedures, click (or tap) Manage Exceptions.

  8. 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.

  9. Click (or tap) Save or Cancel.

Editing exceptions in coverage tables

You can edit exceptions that have been added previously to a coverage table that is attached to an insurance plan.

Tip: You can also edit exceptions in any of the coverage table templates.

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

To edit an exception

  1. If the correct patient is not already selected, use the Patient Search box to access the patient's record.

    Note: You can include inactive patients in the search results by setting the Include inactive patients switch to On.

  2. Do one of the following:

    • On the Patient menu, under General, click (or tap) Overview. The patient's Overview page opens. In the Insurance box, click (or tap) an insurance Plan link.

    • On the Patient menu, under Insurance, click (or tap) Insurance Information. The patient's Insurance Information page opens. Click (or tap) an insurance plan.

    The options for editing insurance information become available.

  3. While viewing an insurance plan that is attached to a patient's record, click (or tap) Coverage Table.

    The Coverage Table dialog box appears.

    Insurance Coverage, %

    Patient Copayment, $

  4. Click (or tap) Manage Exceptions.

    The Exceptions dialog box appears.

  5. Select an exception.

    The options for editing the exception become available.

  6. Select one or multiple procedure codes, and set up the other options on the following tabs as needed:

    • Exception Type

      1. Do one of the following:

        • To add multiple procedures that are not covered, do the following:

          1. Leave Not covered selected as the Exception type.

          2. Click (or tap) Add Bulk Procedures.

            The tab now displays a list of procedure codes.

          3. Select the check boxes that correspond to the procedure codes that are not covered. To search for a procedure, begin typing the code or its description in the Procedure code(s) search box, continue typing as needed to narrow down the procedure code list.

            Note: After searching for and selecting a procedure, to return to viewing the entire procedure code list, delete the search text from the Procedure code(s) search box.

        • To add one procedure code for any exception type, set up the following options:

          • Procedure code - To select a procedure, begin typing the code or its description, continue typing as needed to narrow the results, and then select a code.

          • Exception type - Select one of the following options: Not covered, Downgrade, or Coverage with age limit.

          • Pre-estimate - If the insurance carrier requires that a pre-treatment estimate (pre-authorization) be submitted before treatment can begin for this procedure, select the Required check 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 Downgrade exception type, begin typing the code or description of the substitute procedure to Downgrade coverage to, continue typing as needed to narrow the results, and then select the code.

        • For a Coverage with age limit exception type, set up the following options:

          • Deductible Type - Select the type of deductible that the patient must pay for this procedure.

          • Coverage, % - Enter the percentage of the fee charged that the insurance carrier covers for this procedure. This option is available only for coverage tables that are based on insurance coverage percentages.

          • Copayment, $ - Enter the co-pay that the patient pays for this procedure. This option is available only for coverage tables that are based on fixed, patient copayments.

          • Max age limit - Enter an age limit to specify that the insurance carrier covers this procedure for patients who are of the specified age or younger.

          Insurance Coverage, %

          Patient Copayment, $

      2. Click (or tap) Next.

    • Reason for Exception

      Enter the reason for the exception in coverage for this procedure.

  7. Click (or tap) Done. (This button is available only if the Reason for Exception tab is selected.)

3. 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:


Estimates for a patient's primary or only insurance plan

Do the following:

  1. Calculate the Write-off.

    Terms

    W

    Write-off

    Aproc

    Amount Charged (the procedure's Amount)

    Amax

    Max Allowable Amount (from the plan's Max allowable amount fee schedule)

    Cpat

    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:

        • For a coverage table based on patient copayments ($), take the greater of Amax and Cpat, subtract that greater amount from Aproc, 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 ; Aproc - max (Amax ; Cpat))

        • For a coverage table based on insurance coverage percentages (%), subtract Amax from Aproc, and then set Wpri equal to that difference unless that difference is less than zero, in which case, set Wpri equal to zero.

          W = max (0 ; Aproc - Amax)

      • 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

  2. Calculate the Remaining Deductible.

    Term

    Drem

    Remaining Deductible

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

    1. Do one of the following:

      • For an orthodontic procedure, do the following:

        1. Calculate the Remaining Annual Individual Ortho Deductible:

          Terms

          AIODreq

          Required Annual Individual Ortho Deductible

          AIODmet

          Met Annual Individual Ortho Deductible

          AIODrem

          Remaining Annual Individual Ortho Deductible

          • If AIODreq has no value, then AIODrem = 0

          • If AIODreq = 0, then AIODrem = 0

          • If AIODreq > 0, then AIODrem = AIODreq - AIODmet

        2. Set the Remaining Deductible (Drem) equal to the Remaining Annual Individual Ortho Deductible (AIODrem).

          Drem = AIODrem

      • For an non-orthodontic procedure, do the following:

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

          Terms

          LIDreq

          Required Lifetime Individual Deductible

          LIDmet

          Met Lifetime Individual Deductible

          LIDrem

          Remaining Lifetime Individual Deductible

          • If LIDreq has no value, then LIDrem = 0

          • If LIDreq = 0, then LIDrem = 0

          • If LIDreq > 0, then LIDrem = LIDreq - LIDmet

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

          Terms

          AFDreq

          Required Annual Family Deductible

          AFDmet

          Met Annual Family Deductible

          AFDrem

          Remaining Annual Family Deductible

          • If AFDreq has no value, then AFDrem = 0

          • If AFDreq = 0, then AFDrem = 0

          • If AFDreq > 0, then AFDrem = AFDreq - AFDmet

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

          Terms

          AIDreq

          Required Annual Individual Deductible

          AIDmet

          Met Annual Individual Deductible

          AIDrem

          Remaining Annual Individual Deductible

          • If AIDreq has no value, then AIDrem = 0

          • If AIDreq = 0, then AIDrem = 0

          • If AIDreq > 0, then AIDrem = AIDreq - AIDmet

        4. Calculate the Remaining Deductible. Take the lesser of LIDrem, AFDrem, and AIDrem, and set Drem equal to that lesser amount.

          Drem = min (LIDrem ; AFDrem ; AIDrem)

  3. Calculate the Insurance Portion.

    Terms

    I

    Insurance Portion

    Aproc

    Amount Charged (the procedure's Amount)

    Amax

    Max Allowable Amount (from the plan's Max allowable amount fee schedule)

    Amin

    Min Allowable Amount

    Cpat

    Patient Copay (from the Copayment $ column in the plan's coverage table)

    Cins

    Insurance Coverage Percentage (from the Coverage % column in the plan's coverage table)

    Cexc

    Patient Copay Exception or Insurance Coverage Exception (any applicable exceptions, as indicated in the EXC column, in the plan's coverage table)

    Oins

    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 Amax not exceed Aproc, take the lesser of Aproc and Amax, and then set Amin equal to that lesser amount.

        Amin = min (Aproc ; Amax)

      2. Calculate the Insurance Portion. Do one of the following:

        • Without an Insurance Estimate Override, 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 Cpat equal to Amin.

                  Cpat = Amin

                • 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.

                    Cpat = Cexc

                  • If the patient's age exceeds the specified age, use the default copay.

                    Cpat = Cpat

                • Downgrade. Use the exception instead of the default copay.

                  Cpat = Cexc

              • If there is not an exception for the procedure in the coverage table, use the default copay.

                Cpat = Cpat

            2. Calculate the Insurance Portion. Subtract Cpat from Amin, 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 ; Amin - Cpat)

          • 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 Cins equal to zero.

                  Cins = 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.

                    Cins = Cexc

                  • If the patient's age exceeds the specified age, use the default coverage.

                    Cins = Cins

                • Downgrade. Use the exception instead of the default coverage.

                  Cins = Cexc

              • If there is not an exception for the procedure in the coverage table, use the default coverage.

                Cins = Cins

            2. Calculate the Insurance Portion. Multiply Amin and Cins, 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 ; Amin x Cins)

        • With an Insurance Estimate Override, take the greater of Oins and Amin, 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 (Oins ; Amin))

    • 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:

        • 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 Cpat equal to Aproc.

                Cpat = Aproc

              • 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.

                  Cpat = Cexc

                • If the patient's age exceeds the specified age, use the default copay.

                  Cpat = Cpat

              • Downgrade. Use the exception instead of the default copay.

                Cpat = Cexc

            • If there is not an exception for the procedure in the coverage table, use the default copay.

              Cpat = Cpat

          2. Calculate the Insurance Portion. Subtract Cpat from Aproc, and then set I equal to that difference.

            I = Aproc - Cpat

        • 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 Cins equal to zero.

                Cins = 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.

                  Cins = Cexc

                • If the patient's age exceeds the specified age, use the default coverage.

                  Cins = Cins

              • Downgrade. Use the exception instead of the default coverage.

                Cins = Cexc

            • If there is not an exception for the procedure in the coverage table, use the default coverage.

              Cins = Cins

          2. Calculate the Insurance Portion. Multiply Aproc and Cins, and then set I equal to that product.

            I = Aproc x Cins

      • With an Insurance Estimate Override, set I equal to the override.

        I = Oins

  4. Calculate the Patient Portion.

    Terms

    P

    Patient Portion

    Aproc

    Amount Charged (the procedure's Amount)

    I

    Insurance Portion

    W

    Write-off

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

    P = Aproc - I - W

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

    Terms

    I

    Insurance Portion

    P

    Patient Portion

    Drem

    Remaining Deductible

    Do the following:

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

      I = I - Drem

    • Add P and Drem, and then set P equal to that sum.

      P = P + Drem

  6. Calculate the Remaining Benefit.

    Term

    Brem

    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:

      1. Calculate the Remaining Lifetime Ortho Benefit:

        Terms

        LOBmax

        Maximum Lifetime Ortho Benefit

        LOBused

        Used Lifetime Ortho Benefit

        LOBrem

        Remaining Lifetime Ortho Benefit

        • If LOBmax has no value, then LOBrem = 9,999,999.99

        • If LOBmax = 0, then LOBrem = 0

        • If LOBmax > 0, then LOBrem = LOBmax - LOBused

      2. Set the Remaining Benefit (Brem) equal to the Remaining Lifetime Ortho Benefit (LOBrem).

        Brem = LOBrem

    • For a non-orthodontic procedure, do the following:

      1. Calculate the Remaining Annual Individual Benefit:

        Terms

        AIBmax

        Maximum Annual Individual Benefit

        AIBused

        Used Annual Individual Benefit

        AIBrem

        Remaining Annual Individual Benefit

        • If AIBmax has no value, then AIBrem = 9,999,999.99

        • If AIBmax = 0, then AIBrem = 0

        • If AIBmax > 0, then AIBrem = AIBmax - AIBused

      2. Calculate the Remaining Annual Family Benefit:

        Terms

        AFBmax

        Maximum Annual Family Benefit

        AFBused

        Used Annual Family Benefit

        AFBrem

        Remaining Annual Family Benefit

        • If AFBmax has no value, then AFBrem = 9,999,999.99

        • If AFBmax = 0, then AFBrem = 0

        • If AFBmax > 0, then AFBrem = AFBmax - AFBused

      3. Calculate the Remaining Benefit. Take the lesser of AIBrem and AFBrem, and then set Brem equal to that lesser amount.

        Brem = min (AIBrem ; AFBrem)

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

    Terms

    I

    Insurance Portion

    Brem

    Remaining Benefit

    P

    Patient Portion

    Bover

    Benefit Overage

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

    • If I <= Brem, 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 > Brem, 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.

        Bover = I - Brem

      2. Recalculate the Insurance Portion. Set I equal to Brem.

        I = Brem

      3. Recalculate the Patient Portion. Add P and Bover, and then set P equal to that sum.

        P = P + Bover


Estimates for dual coverage

Do the following:

  1. Calculate the Primary Write-off.

    Terms

    Wpri

    Primary Write-off

    Aproc

    Amount Charged (the procedure's Amount)

    AP.max

    Primary Max Allowable Amount (from the plan's Max allowable amount fee schedule)

    CP.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:

        • For a coverage table based on patient copayments ($), take the greater of AP.max and CP.pat, subtract that from Aproc, and then set Wpri equal to that difference unless that difference is less than zero, in which case, set Wpri equal to zero.

          Wpri = max (0 ; Aproc - max (AP.max ; CP.pat))

        • For a coverage table based on insurance coverage percentages (%), subtract AP.max from Aproc, and then set Wpri equal to that difference unless that difference is less than zero, in which case, set Wpri equal to zero.

          Wpri = max (0 ; Aproc - AP.max)

      • If the billing provider is not contracted with the carrier, set Wpri equal to zero.

        Wpri = 0

    • If a Max allowable amount fee schedule is not selected for the plan, there is not a Primary Write-off, so set Wpri equal to zero.

      Wpri = 0

  2. Calculate the Secondary Write-off.

    Terms

    Wsec

    Secondary Write-off

    Aproc

    Amount Charged (the procedure's Amount)

    AS.max

    Secondary Max Allowable Amount (from the plan's Max allowable amount fee schedule)

    CS.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:

        • For a coverage table based on patient copayments ($), take the greater of AS.max and CS.pat, subtract that from Aproc, and then set Wsec equal to that difference unless that difference is less than zero, in which case, set Wsec equal to zero.

          Wsec = max (0 ; Aproc - max (AS.max ; CS.pat))

        • For a coverage table based on insurance coverage percentages (%), subtract AS.max from Aproc, and then set Wsec equal to that difference unless that difference is less than zero, in which case, set Wsec equal to zero.

          Wsec = max (0 ; Aproc - AS.max)

      • If the billing provider is not contracted with the carrier, set Wsec equal to zero.

        Wsec = 0

    • If a Max allowable amount fee schedule is not selected for the plan, there is not a Secondary Write-off, so set Wsec equal to zero.

      Wsec = 0

  3. Calculate the Max Write-off.

    Terms

    Wmax

    Max Write-off

    Wpri

    Primary Write-off

    Wsec

    Secondary Write-off

    Take the greater of Wpri and Wsec, and then set Wmax equal to that greater amount.

    Wmax = max (Wpri ; Wsec)

  4. Calculate the Primary Remaining Deductible.

    Term

    DP.rem

    Primary Remaining Deductible

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

    1. Do one of the following:

      • For an orthodontic procedure, do the following:

        1. Calculate the Primary Remaining Annual Individual Ortho Deductible:

          Terms

          AIODP.req

          Primary Required Annual Individual Ortho Deductible

          AIODP.met

          Primary Met Annual Individual Ortho Deductible

          AIODP.rem

          Primary Remaining Annual Individual Ortho Deductible

          • If AIODP.req has no value, then AIODP.rem = 0

          • If AIODP.req = 0, then AIODP.rem = 0

          • If AIODP.req > 0, then AIODP.rem = AIODP.req - AIODP.met

        2. Set the Primary Remaining Deductible (DP.rem) equal to the Primary Remaining Annual Individual Ortho Deductible (AIODP.rem).

          DP.rem = AIODP.rem

      • For an non-orthodontic procedure, do the following:

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

          Terms

          LIDP.req

          Primary Required Lifetime Individual Deductible

          LIDP.met

          Primary Met Lifetime Individual Deductible

          LIDP.rem

          Primary Remaining Lifetime Individual Deductible

          • If LIDP.req has no value, then LIDP.rem = 0

          • If LIDP.req = 0, then LIDP.rem = 0

          • If LIDP.req > 0, then LIDP.rem = LIDP.req - LIDP.met

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

          Terms

          AFDP.req

          Primary Required Annual Family Deductible

          AFDP.met

          Primary Met Annual Family Deductible

          AFDP.rem

          Primary Remaining Annual Family Deductible

          • If AFDP.req has no value, then AFDP.rem = 0

          • If AFDP.req = 0, then AFDP.rem = 0

          • If AFDP.req > 0, then AFDP.rem = AFDP.req - AFDP.met

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

          Terms

          AIDP.req

          Primary Required Annual Individual Deductible

          AIDP.met

          Primary Met Annual Individual Deductible

          AIDP.rem

          Primary Remaining Annual Individual Deductible

          • If AIDP.req has no value, then AIDP.rem = 0

          • If AIDP.req = 0, then AIDP.rem = 0

          • If AIDP.req > 0, then AIDP.rem = AIDP.req - AIDP.met

        4. Calculate the Primary Remaining Deductible. Take the lesser of LIDP.rem, AFDP.rem, and AIDP.rem, and set DP.rem equal to that lesser amount.

          DP.rem = min (LIDP.rem ; AFDP.rem ; AIDP.rem)

  5. Calculate the Primary Insurance Portion.

    Terms

    Ipri

    Primary Insurance Portion

    Aproc

    Amount Charged (the procedure's Amount)

    AP.max

    Primary Max Allowable Amount (from the plan's Max allowable amount fee schedule)

    AP.min

    Primary Min Allowable Amount

    CP.pat

    Primary Patient Copay (from the Copayment $ column in the plan's coverage table)

    CP.ins

    Primary Insurance Coverage Percentage (from the Coverage % column in the plan's coverage table)

    CP.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)

    OP.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 AP.max not exceed Aproc, take the lesser of Aproc and AP.max, and then set AP.min equal to that lesser amount.

        AP.min = min (Aproc ; AP.max)

      2. Calculate the Primary Insurance Portion. Do one of the following:

        • Without a Primary Insurance Estimate Override, 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 CP.pat equal to AP.min.

                  CP.pat = AP.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.

                    CP.pat = CP.exc

                  • If the patient's age exceeds the specified age, use the default copay.

                    CP.pat = CP.pat

                • Downgrade. Use the exception instead of the default copay.

                  CP.pat = CP.exc

              • If there is not an exception for the procedure in the coverage table, use the default copay.

                CP.pat = CP.pat

            2. Calculate the Primary Insurance Portion. Subtract CP.pat from AP.min, and then set Ipri equal to that difference unless that difference is less than zero, in which case, set Ipri equal to zero.

              Ipri = max (0 ; AP.min - CP.pat)

          • For a coverage table based on insurance coverage percentages, do the following:

            1. 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 CP.ins equal to zero.

                  CP.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.

                    CP.ins = CP.exc

                  • If the patient's age exceeds the specified age, use the default coverage.

                    CP.ins = CP.ins

                • Downgrade. Use the exception instead of the default coverage.

                  CP.ins = CP.exc

              • If there is not an exception for the procedure in the coverage table, use the default coverage.

                CP.ins = CP.ins

            2. Calculate the Primary Insurance Portion. Multiply AP.min and CP.ins, and then set Ipri equal to that product unless that product is less than zero, in which case, set Ipri equal to zero.

              Ipri = max (0 ; AP.min x CP.ins)

        • With a Primary Insurance Estimate Override, take the greater of OP.ins and AP.min, and then set Ipri equal to that greater amount unless that greater amount is less than zero, in which case, set Ipri equal to zero.

          Ipri = max (0 ; min (OP.ins ; AP.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:

        • 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 CP.pat equal to Aproc.

                CP.pat = Aproc

              • 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.

                  CP.pat = CP.exc

                • If the patient's age exceeds the specified age, use the default copay.

                  CP.pat = CP.pat

              • Downgrade. Use the exception instead of the default copay.

                CP.pat = CP.exc

            • If there is not an exception for the procedure in the coverage table, use the default copay.

              CP.pat = CP.pat

          2. Calculate the Primary Insurance Portion. Subtract CP.pat from Aproc, and then set Ipri equal to that difference.

            Ipri = Aproc - CP.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 CP.ins equal to zero.

                CP.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.

                  CP.ins = CP.exc

                • If the patient's age exceeds the specified age, use the default coverage.

                  CP.ins = CP.ins

              • Downgrade. Use the exception instead of the default coverage.

                CP.ins = CP.exc

            • If there is not an exception for the procedure in the coverage table, use the default coverage.

              CP.ins = CP.ins

          2. Calculate the Primary Insurance Portion. Multiply Aproc and CP.ins, and then set Ipri equal to that product.

            Ipri = Aproc x CP.ins

      • With a Primary Insurance Estimate Override, set Ipri equal to the override.

        Ipri = OP.ins

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

    Terms

    IP.max

    Max Primary Insurance Portion

    Ipri

    Primary Insurance Portion

    DP.rem

    Primary Remaining Deductible

    Subtract DP.rem from Ipri, and then set IP.max equal to that difference.

    IP.max = Ipri - DP.rem

  7. Calculate the Primary Remaining Benefit.

    Term

    BP.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:

      1. Calculate the Primary Remaining Lifetime Ortho Benefit:

        Terms

        LOBP.max

        Primary Maximum Lifetime Ortho Benefit

        LOBP.used

        Primary Used Lifetime Ortho Benefit

        LOBP.rem

        Primary Remaining Lifetime Ortho Benefit

        • If LOBP.max has no value, then LOBP.rem = 9,999,999.99

        • If LOBP.max = 0, then LOBP.rem = 0

        • If LOBP.max > 0, then LOBP.rem = LOBP.max - LOBP.used

      2. Set the Primary Remaining Benefit (BP.rem) equal to the Primary Remaining Lifetime Ortho Benefit (LOBP.rem).

        BP.rem = LOBP.rem

    • For a non-orthodontic procedure, do the following:

      1. Calculate the Primary Remaining Annual Individual Benefit:

        Terms

        AIBP.max

        Primary Maximum Annual Individual Benefit

        AIBP.used

        Primary Used Annual Individual Benefit

        AIBP.rem

        Primary Remaining Annual Individual Benefit

        • If AIBP.max has no value, then AIBP.rem = 9,999,999.99

        • If AIBP.max = 0, then AIBP.rem = 0

        • If AIBP.max > 0, then AIBP.rem = AIBP.max - AIBP.used

      2. Calculate the Primary Remaining Annual Family Benefit:

        Terms

        AFBP.max

        Primary Maximum Annual Family Benefit

        AFBused

        Primary Used Annual Family Benefit

        AFBrem

        Primary Remaining Annual Family Benefit

        • If AFBP.max has no value, then AFBP.rem = 9,999,999.99

        • If AFBP.max = 0, then AFBP.rem = 0

        • If AFBP.max > 0, then AFBP.rem = AFBP.max - AFBP.used

      3. Calculate the Primary Remaining Benefit. Take the lesser of AIBP.rem and AFBP.rem, and then set BP.rem equal to that lesser amount.

        BP.rem = min (AIBP.rem ; AFBP.rem)

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

    Terms

    IP.max

    Max Primary Insurance Portion

    BP.rem

    Primary Remaining Benefit

    Do one of the following:

    • If IP.max <= BP.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.

      IP.max = IP.max

    • If IP.max > BP.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 (IP.max) equal to the Primary Remaining Benefit (BP.rem).

      IP.max = BP.rem

  9. Calculate the Secondary Remaining Deductible.

    Term

    DS.rem

    Secondary Remaining Deductible

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

    1. Do one of the following:

      • For an orthodontic procedure, do the following:

        1. Calculate the Secondary Remaining Annual Individual Ortho Deductible:

          Terms

          AIODS.req

          Secondary Required Annual Individual Ortho Deductible

          AIODS.met

          Secondary Met Annual Individual Ortho Deductible

          AIODS.rem

          Secondary Remaining Annual Individual Ortho Deductible

          • If AIODS.req has no value, then AIODS.rem = 0

          • If AIODS.req = 0, then AIODS.rem = 0

          • If AIODS.req > 0, then AIODS.rem = AIODS.req - AIODS.met

        2. Set the Secondary Remaining Deductible (DS.rem) equal to the Secondary Remaining Annual Individual Ortho Deductible (AIODS.rem).

          DS.rem = AIODS.rem

      • For an non-orthodontic procedure, do the following:

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

          Terms

          LIDS.req

          Secondary Required Lifetime Individual Deductible

          LIDS.met

          Secondary Met Lifetime Individual Deductible

          LIDS.rem

          Secondary Remaining Lifetime Individual Deductible

          • If LIDS.req has no value, then LIDS.rem = 0

          • If LIDS.req = 0, then LIDS.rem = 0

          • If LIDS.req > 0, then LIDS.rem = LIDS.req - LIDS.met

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

          Terms

          AFDS.req

          Secondary Required Annual Family Deductible

          AFDS.met

          Secondary Met Annual Family Deductible

          AFDS.rem

          Secondary Remaining Annual Family Deductible

          • If AFDS.req has no value, then AFDS.rem = 0

          • If AFDS.req = 0, then AFDS.rem = 0

          • If AFDS.req > 0, then AFDS.rem = AFDS.req - AFDS.met

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

          Terms

          AIDS.req

          Secondary Required Annual Individual Deductible

          AIDS.met

          Secondary Met Annual Individual Deductible

          AIDS.rem

          Secondary Remaining Annual Individual Deductible

          • If AIDS.req has no value, then AIDS.rem = 0

          • If AIDS.req = 0, then AIDS.rem = 0

          • If AIDS.req > 0, then AIDS.rem = AIDS.req - AIDS.met

        4. Calculate the Secondary Remaining Deductible. Take the lesser of LIDS.rem, AFDS.rem, and AIDS.rem, and set DS.rem equal to that lesser amount.

          DS.rem = min (LIDS.rem ; AFDS.rem ; AIDS.rem)

  10. Calculate the Secondary Insurance Portion.

    Terms

    Isec

    Secondary Insurance Portion

    Aproc

    Amount Charged (the procedure's Amount)

    AS.max

    Secondary Max Allowable Amount (from the secondary plan's Max allowable amount fee schedule)

    AS.min

    Secondary Min Allowable Amount

    CS.pat

    Secondary Patient Copay (from the Copayment $ column in the secondary plan's coverage table)

    CS.ins

    Secondary Insurance Coverage Percentage (from the Coverage % column in the secondary plan's coverage table)

    CS.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)

    OS.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 AS.max not exceed Aproc, take the lesser of Aproc and AS.max, and then set AS.min equal to that lesser amount.

        AS.min = min (Aproc ; AS.max)

      2. Calculate the Secondary Insurance Portion. Do one of the following:

        • Without a Secondary Insurance Estimate Override:

          • 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 CS.pat equal to AS.min.

                  CS.pat = AS.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.

                    CS.pat = CS.exc

                  • If the patient's age exceeds the specified age, use the default copay.

                    CS.pat = CS.pat

                • Downgrade. Use the exception instead of the default copay.

                  CS.pat = CS.exc

              • If there is not an exception for the procedure in the coverage table, use the default copay.

                CS.pat = CS.pat

            2. Calculate the Secondary Insurance Portion. Use one of the following methods for coordinating benefits:

              • Traditional: Subtract CS.pat from AS.min, and then set Isec equal to that difference unless that difference is less than zero, in which case, set Isec equal to zero.

                Isec = max (0; AS.min - CS.pat)

              • Maintenance of Benefits: Subtract Wsec, Ipri, and CS.pat from Aproc, and then set Isec equal to that difference unless that difference is less than zero, in which case, set Isec equal to zero.

                Isec = max (0 ; Aproc - Wsec - Ipri - CS.pat)

              • Carve Out/Non-duplication: Subtract CS.pat and Ipri from AS.min, and then set Isec equal to that difference unless that difference is less than zero, in which case, set Isec equal to zero.

                Isec = max (0 ; AS.min - CS.pat - Ipri)

          • 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 CS.ins equal to zero.

                  CS.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.

                    CS.ins = CS.exc

                  • If the patient's age exceeds the specified age, use the default coverage.

                    CS.ins = CS.ins

                • Downgrade. Use the exception instead of the default coverage.

                  CS.ins = CS.exc

              • If there is not an exception for the procedure in the coverage table, use the default coverage.

                CS.ins = CS.ins

            2. Calculate the Secondary Insurance Portion. Use one of the following methods for coordinating benefits:

              • Traditional: Multiply AS.min and CS.ins, and then set Isec equal to that product unless that product is less than zero, in which case, set Isec equal to zero.

                Isec = max (0 ; AS.min x CS.ins)

              • Maintenance of Benefits: Subtract Ipri from AS.min, multiply that difference and CS.ins, and then set Isec equal to the resulting product unless that product is less than zero, in which case, set Isec equal to zero.

                Isec = max (0 ; (AS.min - Ipri) x CS.ins)

              • Carve Out/Non-duplication: Multiply AS.min and CS.ins, subtract Ipri from that product, and then set Isec equal to the resulting difference unless that difference is less than zero, in which case, set Isec equal to zero.

                Isec = max (0 ; (AS.min x CS.ins) - Ipri)

        • With a Secondary Insurance Estimate Override, use one of the following methods for coordinating benefits:

          • Traditional: Take the greater of OS.ins and AS.min, and then set Isec equal to that greater amount unless that greater amount is less than zero, in which case, set Isec equal to zero.

            Isec = max (0; min (OS.ins ; AS.min))

          • Maintenance of Benefits: Set Isec equal to the override.

            Isec = OS.ins

          • Carve Out/Non-duplication: Set Isec equal to the override.

            Isec = OS.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:

        • 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 CS.pat equal to Aproc.

                CS.pat = Aproc

              • 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.

                  CS.pat = CS.exc

                • If the patient's age exceeds the specified age, use the default copay.

                  CS.pat = CS.pat

              • Downgrade. Use the exception instead of the default copay.

                CS.pat = CS.exc

            • If there is not an exception for the procedure in the coverage table, use the default copay.

              CS.pat = CS.pat

          2. Calculate the Secondary Insurance Portion. Use one of the following methods for coordinating benefits:

            • Traditional: Subtract CS.pat from Aproc, and then set Isec equal to that difference.

              Isec = Aproc - CS.pat

            • Maintenance of Benefits: Subtract Ipri and CS.pat from Aproc, and then set Isec equal to that difference.

              Isec = Aproc - Ipri - CS.pat

            • Carve Out/Non-duplication: Subtract CS.pat and Ipri from Aproc, and then set Isec equal to that difference.

              Isec = Aproc- CS.pat - Ipri

        • 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 CS.ins equal to zero.

                CS.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.

                  CS.ins = CS.exc

                • If the patient's age exceeds the specified age, use the default coverage.

                  CS.ins = CS.ins

              • Downgrade. Use the exception instead of the default coverage.

                CS.ins = CS.exc

            • If there is not an exception for the procedure in the coverage table, use the default coverage.

              CS.ins = CS.ins

          2. Calculate the Secondary Insurance Portion. Use one of the following methods for coordinating benefits:

            • Traditional: Multiply Aproc and CS.ins, and then set Isec equal to that product.

              Isec = Aproc x CS.ins

            • Maintenance of Benefits: Subtract Ipri from Aproc, multiply that difference and CS.ins, and then set Isec equal to the resulting product.

              Isec = (Aproc - Ipri) x CS.ins

            • Carve Out/Non-duplication: Multiply Aproc and CS.ins, subtract Ipri from that product, and then set Isec equal to that product.

              Isec = (Aproc x CS.ins) - Ipri

      • With a Secondary Insurance Estimate Override, set Isec equal to the override.

        Isec = OS.ins

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

    Terms

    IS.max

    Max Secondary Insurance Portion

    Isec

    Secondary Insurance Portion

    DS.rem

    Secondary Remaining Deductible

    Subtract DS.rem from Isec, and then set Imax equal to that difference.

    Imax = Isec - Drem

  12. Calculate the Secondary Remaining Benefit.

    Terms

    BS.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:

      1. Calculate the Secondary Remaining Lifetime Ortho Benefit:

        Terms

        LOBS.max

        Secondary Maximum Lifetime Ortho Benefit

        LOBS.used

        Secondary Used Lifetime Ortho Benefit

        LOBS.rem

        Secondary Remaining Lifetime Ortho Benefit

        • If LOBS.max has no value, then LOBS.rem = 9,999,999.99

        • If LOBS.max = 0, then LOBS.rem = 0

        • If LOBS.max > 0, then LOBS.rem = LOBS.max - LOBS.used

      2. Set the Secondary Remaining Benefit (BS.rem) equal to the Secondary Remaining Lifetime Ortho Benefit (LOBS.rem).

        BS.rem = LOBS.rem

    • For a non-orthodontic procedure, do the following:

      1. Calculate the Secondary Remaining Annual Individual Benefit:

        Terms

        AIBS.max

        Secondary Maximum Annual Individual Benefit

        AIBS.used

        Secondary Used Annual Individual Benefit

        AIBS.rem

        Secondary Remaining Annual Individual Benefit

        • If AIBS.max has no value, then AIBS.rem = 9,999,999.99

        • If AIBS.max = 0, then AIBS.rem = 0

        • If AIBS.max > 0, then AIBS.rem = AIBS.max - AIBS.used

      2. Calculate the Secondary Remaining Annual Family Benefit:

        Terms

        AFBS.max

        Secondary Maximum Annual Family Benefit

        AFBS.used

        Secondary Used Annual Family Benefit

        AFBS.rem

        Secondary Remaining Annual Family Benefit

        • If AFBS.max has no value, then AFBS.rem = 9,999,999.99

        • If AFBS.max = 0, then AFBS.rem = 0

        • If AFBS.max > 0, then AFBS.rem = AFBS.max - AFBS.used

      3. Calculate the Secondary Remaining Benefit. Take the lesser of AIBS.rem and AFBS.rem, and then set BS.rem equal to that lesser amount.

        BS.rem = min (AIBS.rem ; AFBS.rem)

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

    Terms

    IS.max

    Max Secondary Insurance Portion

    BS.rem

    Secondary Remaining Benefit

    Do one of the following:

    • If IS.max<= BS.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.

      IS.max = IS.max

    • If IS.max > BS.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 (IS.max) equal to the Secondary Remaining Benefit (BS.rem).

      IS.max = BS.rem

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

    Terms

    Itot

    Total Insurance Portion (for dual coverage)

    IP.max

    Max Primary Insurance Portion

    IS.max

    Max Secondary Insurance Portion

    Aproc

    Amount Charged (the procedure's Amount)

    Pmax

    Max Patient Portion (for dual coverage)

    Wmax

    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 IP.max and IS.max, and then set Itot equal to that sum.

        Itot = sum (IP.max + IS.max)

      2. Do one of the following:

        • If Itot >= Aproc, do the following:

          • Set the Total Insurance Portion (Itot) equal to Aproc.

            Itot = Aproc

          • Set the Max Patient Portion (Pmax) equal to zero.

            Pmax = 0

          • Set the Max Write-off (Wmax) equal to zero.

            Wmax = 0

        • If Itot < Aproc, do one of the following:

          • With the Insurance Sum (S) equal to Itot + Wmax, if S >= Aproc, do the following:

            1. Set the Max Patient Portion (Pmax) equal to zero.

              Pmax = 0

            2. Do one of the following:

              • If S = Aproc, adjustments are not needed. The Max Write-off and the Total Insurance Portion stay the same.

                Wmax = Wmax

                Itot = Itot

              • If S > Aproc, make adjustments in the following order (until S = Aproc):

                1. If S > Aproc, reduce Wmax until S = Aproc or until Wmax = 0, whichever comes first.

                2. If Wmax = 0, and if S > Aproc, reduce Itot (by reducing IS.max) until S = Aproc.

          • With the Insurance Sum (S) equal to Itot + Wmax, if S < Aproc, do the following:

            • Calculate the Max Patient Portion. Subtract Itot and Wmax from Aproc, and then set Pmax equal to that difference.

              Pmax = Aproc - Itot - Wmax

            • The Max Write-off and the Total Insurance Portion stay the same.

              Wmax = Wmax

              Itot = Itot

    • For the Traditional method of coordinating benefits, do the following:

      1. Calculate the Total Insurance Portion. Add IP.max and IS.max, and then set Itot equal to that sum.

        Itot = sum (IP.max + IS.max)

      2. Calculate the Max Patient Portion. Subtract Wmax, IP.max, and IS.max from Aproc, and then set Pmax equal to that difference unless that difference is less than zero, in which case, set Pmax equal to zero.

        Pmax= max (0; Aproc - Wmax - IP.max - IS.max)

      3. Set the Sum of the Terms (s) equal to the sum of Wmax, IP.max, IS.max, and Pmax.

        S = sum (Wmax + IP.max + IS.max + Pmax)

      4. Do one of the following:

        • If S = Aproc, adjustments are not needed. The Max Write-off and the Total Insurance Portion stay the same.

          Wmax = Wmax

          Itot = Itot

        • If S > Aproc, make adjustments in the following order (until S = Aproc):

          1. If S > Aproc, reduce Pmax until S = Aproc or until Pmax = 0, whichever comes first.

          2. If Pmax = 0 and if S > Aproc, reduce Wmax until S = Aproc or until Wmax = 0, whichever comes first.

          3. If Pmax = 0, if Wmax = 0, and if S > Aproc, reduce Itot (by reducing IS.max) until S = Aproc.