Troubleshooting Insurance Estimates

This document provides troubleshooting steps to help ensure that insurance estimates are calculated accurately. Currently, the only types of commercial insurance plans that Dentrix Ascend supports are PPO (Preferred Provider Organization) and indemnity.

Pre-requisites

Is the insurance plan attached to the patient correctly, and is it active?

How do I verify that the insurance plan is attached to the patient correctly and is active?

  1. On the Patient menu, under Insurance, click (or tap) Insurance Information.

    The patient's Insurance Information page opens.

  2. Verify that the insurance plan is listed and that the Coverage Type is correct.

    Note: If the plan appears only if the Show Expired Plans switch is set to On, you need to change the coverage period or add a new plan, unless the patient is no longer covered by insurance.

How do I attach the insurance plan to the patient?

  1. On the Patient menu, under Insurance, click (or tap) Insurance Information.

    The patient's Insurance Information page opens.

  2. On a patient's Insurance Information page, click (or tap) Add Plan.

    The options for entering insurance information become available.

  3. 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.)

  4. 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:

      1. Select Search by Carrier/Plan/Employer.

      2. 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:

      1. Select Search by Patient.

      2. 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:

      1. 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.

      2. 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:

          1. Click (or tap) Add Carrier.

            The options for adding a carrier become available.

          2. 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).

          3. 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). Proceed to the next step.

          4. Set up the other options as needed:

            • 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 after you click (or tap) Save.

            • 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).

          5. Click (or tap) Save.

        The options for adding a plan become available.

      3. 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, 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.

        • PPO Contracted Fee Schedule - (Use for PPO plans only.) The schedule of allowed charges for the insurance plan. 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.

        • CAP Plan Fees - (Use for capitation plans only.) The selected fee schedule will be used to determine a patient's co-pay and the recommended write-off.

        • Coverage Table - The coverage table for the plan. You can change the default deductible type and coverage percentage each procedure code range in the coverage table. Access to this dialog box is available only if a Plan/Employer Name has been entered.

          Note: You can also add exceptions, but currently, only the "not covered" exception in coverage tables is used by Dentrix Ascend to automatically calculate insurance estimates.

        • 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.

        • 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.

      4. Click (or tap) Save.

  5. Set up the rest of the options as needed, such as the subscriber ID, relation to the subscriber, coverage type, 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.

    • 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.

    • 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.

    • 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.

    • Coverage Type - The coverage order of the plan (such as Primary or Secondary). The number of items that are available on the list depends on the number of plans that have already been set up for this patient. If there are no plans, only Primary is an option; if there is one plan, Primary and Secondary are options; if there are two plans, Primary, Secondary, and Tertiary are options; and so on.

    • 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.

    • 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.

  6. Click (or tap) Coverage Table to edit the coverage table for the insurance plan.

  7. Click (or tap) Benefits to edit the deductibles and benefits for the insurance plan. Access to the deductibles and benefits is available only if a subscriber and a plan have been selected. When you attempt to access the deductibles and benefits, if you have not already saved the plan, a message appears and states that you must save the plan before you can access the deductibles and benefits. Click (or tap) Yes to save the plan and continue.

  8. Click (or tap) Save.

  9. Click (or tap) Save.

How do I change the insurance plan's coverage order?

  1. On the Patient menu, under Insurance, click (or tap) Insurance Information.

    The patient's Insurance Information page opens.

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

    The options for editing insurance information become available.

  3. From the Coverage Type list, select the coverage order of the plan (such as Primary or Secondary).

  4. Click (or tap) Save.

How do I edit the coverage period?

  1. On the Patient menu, under Insurance, click (or tap) Insurance Information.

    The patient's Insurance Information page opens.

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

    The options for editing insurance information become available.

  3. 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.

  4. Click (or tap) Save.

Is the procedure date within the coverage period?

How do I verify that the coverage period of the insurance plan is correct?

  1. On the Patient menu, under Insurance, click (or tap) Insurance Information.

    The patient's Insurance Information page opens.

  2. Verify that the insurance plan is listed, that the Coverage Type is correct, and that the Coverage Period is correct.

    Note: If the plan appears only if the Show Expired Plans switch is set to On, you need to change the coverage period or add a new plan, unless the patient is no longer covered by insurance.

How do I verify that the date of the posted procedure is correct?

  1. On the Patient menu, under Financial, click (or tap) Ledger.

    The patient's Ledger page opens.

  2. Verify that the posted procedure's Date is correct.

How do I edit the coverage period?

  1. On the Patient menu, under Insurance, click (or tap) Insurance Information.

    The patient's Insurance Information page opens.

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

    The options for editing insurance information become available.

  3. 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.

  4. Click (or tap) Save.

How do I edit the procedure date?

  1. On the Patient menu, under Financial, click (or tap) Ledger.

    The patient's Ledger page opens.

  2. Select a procedure.

    The Edit Procedure dialog box appears.

  3. Change the Date of the procedure.

  4. Click (or tap) Save.

Is the procedure amount correct?

How do I verify that the amount of the posted procedure is correct?

  1. On the Patient menu, under Financial, click (or tap) Ledger.

    The patient's Ledger page opens.

  2. Verify that the posted procedure's Amount is correct. If necessary, you can determine where the amount came from.

How do I verify where the procedure amount came from?

  1. Determine which, or if any, fee schedule is attached to the rendering provider's user account.

  2. Do one of the following:

    • If the wrong fee schedule is attached, or a fee schedule is not attached but should be, select the correct one, and then look up the fee for the procedure in that fee schedule.

    • If the correct fee schedule is attached, look up the fee for the procedure in that fee schedule. If the procedure amount does not match the rendering provider's fee for the procedure, the procedure amount was manually overridden when the procedure was posted.

    • If a fee schedule is not attached and should not be, look up the fee for the procedure in the location's preferred fee schedule. If the procedure amount does not match the location's fee for the procedure, the procedure amount was manually overridden when the procedure was posted.

How do I verify that the correct fee schedule is attached to the rendering provider?

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

    The User Accounts page opens.

  2. On the User Accounts page, select a user account.

    The options for editing the user account become available.

  3. On the Fees tab, verify that the provider's Fee Schedule is correct.

  4. Do one of the following:

    • If the rendering provider has the correct fee schedule attached to his or her user account, verify that the fee for the procedure in that fee schedule is correct.

    • If the rendering provider does not have a fee schedule attached to his or her user account but should, or if the wrong fee schedule is selected, select the correct fee schedule, or create a fee schedule (which you can attach to the provider later).

    • If the rendering provider does not have a fee schedule attached to his or her user account and should not, verify that the fee for the procedure in the location's preferred fee schedule is correct.

How do I verify that the fee in the rendering provider's or location's fee schedule is correct?

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

    The Fee Schedules page opens.

  2. Select a fee schedule.

    The options for editing the fee schedule become available.

  3. If the fee schedule has multiple versions, select the correct version (if not already selected) from the Fee schedule version list. This list is available only if the fee schedule has multiple versions.

  4. Locate the procedure, and verify that its fee (under Current Fee) is correct.

How do I verify that the correct fee schedule is attached to the location?

  1. From the Location menu, select the correct location.

  2. On the Settings menu, under Location, click (or tap) Location Information.

    The Location Information page opens.

  3. Verify that the Preferred Fee Schedule is correct.

How do I attach a fee schedule to or select a different fee schedule for the rendering provider?

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

    The User Accounts page opens.

  2. On the User Accounts page, select a user account.

    The options for editing the user account become available.

  3. On the Fees tab, select the provider's Fee Schedule.

  4. Click (or tap) Save.

How do I select a different fee schedule for the location?

  1. From the Location menu, select the correct location.

  2. On the Settings menu, under Location, click (or tap) Location Information.

    The Location Information page opens.

  3. Select the location's Preferred Fee Schedule.

  4. Click (or tap) Save.

How do I create a fee schedule for the rendering provider or location?

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

    The Fee Schedules page opens.

  2. Click (or tap) Create New.

    The options for creating a fee schedule become available.

  3. In the Name of fee schedule box, enter a name for the fee schedule.

  4. To base this fee schedule on an existing fee schedule, select the fee schedule that you want to copy from the Copy existing list, and then click (or tap) Copy.

  5. For each procedure, enter or change the fee that you charge as needed.

  6. Click (or tap) Save.

After you have created the fee schedule and entered the correct fees into that fee schedule, attach the fee schedule to the rendering provider or location.

How do I edit the rendering provider's or location's fee for the procedure?

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

    The Fee Schedules page opens.

  2. Select a fee schedule.

    The options for editing the fee schedule become available.

  3. If the fee schedule has multiple versions, select the correct version (if not already selected) from the Fee schedule version list. This list is available only if the fee schedule has multiple versions.

  4. Update the fee for the procedure.

  5. Click (or tap) Save.

After you have corrected the fee, update the procedure amount.

How do I update the procedure amount?

  1. On the Patient menu, under Financial, click (or tap) Ledger.

    The patient's Ledger page opens.

  2. Select a procedure.

    The Edit Procedure dialog box appears.

  3. Change the Amount.

    If the Amount entered is different than the fee for the selected procedure in the patient's discount fee schedule (if applicable) or the provider's fee schedule (or if not applicable, the default fee for the procedure code), the recommended amount appears next to the box.

  4. To use the recommended amount, either click (or tap) the recommendation to insert that value into the Amount box, or select the Update procedure code/amount to the recommended value above? check box to use the recommended value automatically when you save the procedure.

  5. Click (or tap) Save.

How do I manually override the procedure amount?

  1. On the Patient menu, under Financial, click (or tap) Ledger.

    The patient's Ledger page opens.

  2. Select a procedure.

    The Edit Procedure dialog box appears.

  3. Change the Amount.

    If the Amount entered is different than the fee for the selected procedure in the patient's discount fee schedule (if applicable) or the provider's fee schedule (or if not applicable, the default fee for the procedure code), the recommended amount appears next to the box.

  4. To not use the recommended amount, clear the Update procedure code/amount to the recommended value above? check box.

  5. Click (or tap) Save.

What is the insurance plan's type?

How do I verify what the insurance plan's type is?

To verify what the insurance plan's type is

  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. For PPO and Indemnity plans, make sure that Commerical Insurance is selected in the Source of Payment list.

  5. For a PPO plan, verify that the correct fee schedule is selected for the PPO Contracted Fee Schedule. For an indemnity plan, make sure that no fee schedule is selected.

How do I change the insurance plan's type?

  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. For PPO and Indemnity plans, make sure that Commerical Insurance is selected in the Source of Payment list.

  5. For a PPO plan, verify that the correct fee schedule is selected for the PPO Contracted Fee Schedule. For an indemnity plan, make sure that no fee schedule is selected.

How do I attach a fee schedule to or select a different fee schedule for the 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. For a PPO plan only, select the correct PPO Contracted Fee Schedule.

After you have attached a fee schedule or selected a different fee schedule, verify that the allowed amount for the procedure in that fee schedule is correct, if you have not already, and change the allowed amount if necessary.

How do I create a fee schedule for the insurance plan?

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

    The Fee Schedules page opens.

  2. Click (or tap) Create New.

    The options for creating a fee schedule become available.

  3. In the Name of fee schedule box, enter a name for the fee schedule.

  4. To base this fee schedule on an existing fee schedule, select the fee schedule that you want to copy from the Copy existing list, and then click (or tap) Copy.

  5. For each procedure, enter or change the fee that you charge as needed.

  6. Click (or tap) Save.

After you have created the fee schedule and entered the correct allowed amounts into that fee schedule, attach the fee schedule to the insurance plan.

How do I edit the insurance carrier's allowed amount for the procedure?

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

    The Fee Schedules page opens.

  2. Select a fee schedule.

    The options for editing the fee schedule become available.

  3. 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.

  4. Enter the correct New Fee for the procedure.

  5. Click (or tap) Save.

Is the rendering provider under contract with the carrier (PPO only)?

How do I verify that the rendering provder is under contract with the insurance carrier?

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

    The User Accounts page opens.

  2. On the User Accounts page, select a user account.

    The options for editing the user account become available.

  3. On the Fees 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 that the check box next to that carrier is selected.

How do I make the rendering provider contracted with the insurance carrier?

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

    The User Accounts page opens.

  2. On the User Accounts page, select a user account.

    The options for editing the user account become available.

  3. On the Fees 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 select the check box next to that carrier.

  4. Click (or tap) Save.

Is the insurance carrier's allowed amount correct (PPO only)?

How do I verify that the allowed fee in the insurance plan's fee schedule is correct?

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

    The Fee Schedules page opens.

  2. Select a fee schedule.

    The options for editing the fee schedule become available.

  3. If the fee schedule has multiple versions, select the correct version (if not already selected) from the Fee schedule version list. This list is available only if the fee schedule has multiple versions.

  4. Locate the procedure, and verify that its fee (under Current Fee) is correct.

How do I edit the insurance carrier's allowed amount for the procedure?

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

    The Fee Schedules page opens.

  2. Select a fee schedule.

    The options for editing the fee schedule become available.

  3. If the fee schedule has multiple versions, select the correct version (if not already selected) from the Fee schedule version list. This list is available only if the fee schedule has multiple versions.

  4. Update the fee for the procedure.

  5. Click (or tap) Save.

Is the deductible type for the procedure in the coverage table correct?

How do I verify that the deductible type for the procedure in the coverage table is correct?

  1. On the Patient menu, under Insurance, click (or tap) Insurance Information.

    The patient's Insurance Information page opens.

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

    The options for editing insurance information become available.

  3. Click (or tap) Coverage Table.

    The Coverage Table dialog box appears.

  4. Locate the correct Code Range for the procedure, and verify that the Deductible Type is correct.

How do I change the deductible type for the procedure in the coverage table?

  1. On the Patient menu, under Insurance, click (or tap) Insurance Information.

    The patient's Insurance Information page opens.

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

    The options for editing insurance information become available.

  3. Click (or tap) Coverage Table.

    The Coverage Table dialog box appears.

  4. Select a procedure code range.

    The options for editing the range become available.

  5. Select the applicable Deductible Type for the procedures in the range.

Is the coverage percentage for the procedure in the coverage table correct?

How do I verify that the coverage percentage for the procedure in the coverage table is correct?

  1. On the Patient menu, under Insurance, click (or tap) Insurance Information.

    The patient's Insurance Information page opens.

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

    The options for editing insurance information become available.

  3. Click (or tap) Coverage Table.

    The Coverage Table dialog box appears.

  4. Locate the correct Code Range for the procedure, and verify that the Coverage % is correct.

  5. If there are Exceptions for the Code Range, verify if there is an exception for the procedure.

How do I change the coverage percentage for the procedure in the coverage table?

  1. On the Patient menu, under Insurance, click (or tap) Insurance Information.

    The patient's Insurance Information page opens.

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

    The options for editing insurance information become available.

  3. Click (or tap) Coverage Table.

    The Coverage Table dialog box appears.

  4. Select a procedure code range.

    The options for editing the range become available.

  5. Change the Coverage % for the procedures in the range.

  6. If there are Exceptions for the Code Range, verify if there is an exception for the procedure.

Is there an exception for the procedure in the coverage table?

How do I verify if there is an exception for the procedure in the coverage table?

  1. On the Patient menu, under Insurance, click (or tap) Insurance Information.

    The patient's Insurance Information page opens.

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

    The options for editing insurance information become available.

  3. Click (or tap) Coverage Table.

    The Coverage Table dialog box appears.

  4. If there are Exceptions for the Code Range that the procedure corresponds to, click (or tap) Manage Exceptions.

    The Exceptions dialog box appears.

  5. Verify if the procedure's Procedure Code appears in the list. If so, you can verify that the exception options for the procedure are correct.

How do I verify that the exception options for the procedure in the coverage table are correct?

  1. On the Patient menu, under Insurance, click (or tap) Insurance Information.

    The patient's Insurance Information page opens.

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

    The options for editing insurance information become available.

  3. Click (or tap) Coverage Table.

    The Coverage Table dialog box appears.

  4. Click (or tap) Manage Exceptions.

    The Exceptions dialog box appears.

  5. Select the exception for the procedure's Procedure Code.

    The options for editing the exception become available.

  6. Verify that the options on the following tabs are correct:

    • Exception Type

      1. Verify that the Procedure Code, Exception type, and Pre-estimate options are set up correctly.

      2. Click (or tap) Next.

    • Type Specific 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, verify that the substitute procedure to Downgrade coverage to is correct.

        • For a Coverage with age limit exception type, verify that the Deductible Type, Coverage %, and Max age limit are correct.

      2. Click (or tap) Next.

    • Reason for Exception

      The reason for the exception does not affect the calculation of an insurance estimate.

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

How do I change the exception for the procedure in the coverage table?

  1. On the Patient menu, under Insurance, click (or tap) Insurance Information.

    The patient's Insurance Information page opens.

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

    The options for editing insurance information become available.

  3. Click (or tap) Coverage Table.

    The Coverage Table dialog box appears.

  4. Click (or tap) Manage Exceptions.

    The Exceptions dialog box appears.

  5. Select the exception for the procedure's Procedure Code.

    The options for editing the exception become available.

  6. Change the options on the following tabs as needed:

    • Exception Type

      1. 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.

    • Type Specific 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.

          • 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.

      2. Click (or tap) Next.

    • Reason for Exception

      The reason for the exception does not affect the calculation of an insurance estimate, but you can enter the reason or change any existing text.

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

Are the deductible amounts (required and met) for the patient's insurance plan correct?

How do I verify that the patient's deductible amounts are correct?

  1. On the Patient menu, under Insurance, click (or tap) Insurance Information.

    The patient's Insurance Information page opens.

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

    The options for editing insurance information become available.

  3. Click (or tap) Benefits.

    The Deductibles and Benefits dialog box appears.

  4. Verify that the Deductibles are correct.

How do I change the deductible amounts?

  1. On the Patient menu, under Insurance, click (or tap) Insurance Information.

    The patient's Insurance Information page opens.

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

    The options for editing insurance information become available.

  3. Click (or tap) Benefits.

    The Deductibles and Benefits dialog box appears.

  4. Change the Required and Met amounts for the Deductibles as needed.

  5. Click (or tap) Save.

Are the benefit amounts (maximum and used) for the patient's insurance plan correct?

How do I verify that the patient's benefit amounts are correct?

  1. On the Patient menu, under Insurance, click (or tap) Insurance Information.

    The patient's Insurance Information page opens.

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

    The options for editing insurance information become available.

  3. Click (or tap) Benefits.

    The Deductibles and Benefits dialog box appears.

  4. Verify that the Benefits are correct.

How do I change the benefit amounts?

  1. On the Patient menu, under Insurance, click (or tap) Insurance Information.

    The patient's Insurance Information page opens.

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

    The options for editing insurance information become available.

  3. Click (or tap) Benefits.

    The Deductibles and Benefits dialog box appears.

  4. Change the Maximum and Used amounts for the Benefits as needed.

  5. Click (or tap) Save.

Calculations

How are insurance estimates calculated in the Ledger and Treatment Planner?

In the Ledger and Treatment Planner, 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.

Currently, the only types of commercial insurance plans that Dentrix Ascend supports are PPO (Preferred Provider Organization) and indemnity.

Notes:

How is the Insurance Portion (I) calculated?

The Insurance Portion (I) is calculated in the following manner:

  1. Calculate the Remaining Benefits (B).

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

    • For an orthodontic procedure, use one of the following calculations:

      BM represents the Maximum Ortho Benefits
      BU represents the Used Ortho Benefits

      • If BM has no value, then B = $9,999,999.99

      • If BM - BU < 0, then B = 0

      • If BM > 0, then B = BM - BU

    • For a non-orthodontic procedure, use one of the following calculations:

      BI represents the Maximum Individual Benefits
      BF represents the Maximum Family Benefits
      BU represents the Used Benefits

      • If BI has no value:

        • If BF has no value, then B = $9,999,999.99

        • If BF - BU < 0, then B = 0

        • If BF > 0, then B = BF - BU

      • If BI - BU < 0, then B = 0

      • If BI > 0:

        • If BF has no value, then B = BI - BU

        • If BF - BU < 0, then B = 0

        • If BF > 0:

          • If BI - BU > BF - BU, then B = BF - BU

          • If BI - BU < BF - BU, then B = BI - BU

  2. Calculate the Required Deductible (D).

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

    • For an orthodontic procedure, use one of the following calculations:

      DI represents the Individual Lifetime Ortho Deductible
      DM represents the Ortho Deductible Met

      • If DI has no value or is 0, then D = 0

      • If DI > 0:

        • If DI - DM < 0, then D = 0

        • If DI - DM > 0, then D = DI - DM

    • For a non-orthodontic procedure (using the preventive, basic, or major deductible type), use one of the following calculations:

      DI represents the Annual Individual Deductible
      DF represents the Annual Family Deductible
      DL represents the Lifetime Individual Deductible
      DM represents the Deductible Met

      • If DI - DM < 0, then D = 0

      • If DI - DM > 0:

        • If DF - DM < 0, then D = 0

        • If DF - DM > 0:

          • If DL - DM < 0, then D = 0

          • If DL - DM > 0:

            • If DF - DM > DI - DM:

              • If DI - DM >= DL - DM, then D = DI - DM

              • If DI - DM < DL - DM, then D = DL - DM

            • If DF - DM < DI - DM:

              • If DF - DM >= DL - DM, then D = DL - DM

              • If DF - DM < DL - DM, then D = DF - DM

  3. If there is an Insurance Estimate Override (V) for the procedure, then I = V (ignore the steps that follow); otherwise, skip this step.

  4. Calculate the Initial Covered Amount (C1).

    • For a PPO plan (a fee schedule must be attached to the plan, and the provider must be under contract with the carrier), do the following:

      A represents the Procedure Amount
      F represents the Allowed Fee (from the plan's fee schedule)
      A2 represents the Allowed Amount for Procedure
      PE represents the Coverage Percentage from Exception
      P represents the Coverage Percentage from Coverage Table
      PD represents the Coverage Percentage for Downgrade Procedure Code from Coverage Table

      1. Use one of the following calculations:

        • If F < A, then A2 = F

        • If F > A, then A2 = A

      2. Use one of the following calculations:

        • If there is an applicable exception in the coverage table, calculate the coverage according to the exception type:

          • Not covered: C1 = 0

          • Coverage with Maximum Age Limit:

            • If the patient's age does not exceed the specified age, then C1 = A2 × PE

            • If the patient's age exceeds the specified age, then C1 = A2 × P

          • Downgrade: C1 = A2 × PD

        • If there is not an applicable exception, then C1 = A2 × P

    • For an indemnity plan (a fee schedule must not be attached to the plan), use one of the following calculations:

      A represents the Procedure Amount
      PE represents the Coverage Percentage from Exception
      P represents the Coverage Percentage from Coverage Table
      PD represents the Coverage Percentage for Downgrade Procedure Code from Coverage Table

      • If there is an applicable exception in the coverage table, calculate the coverage according to the exception type:

        • Not covered: C1 = 0

        • Coverage with Maximum Age Limit:

          • If the patient's age does not exceed the specified age, then C1 = A × PE

          • If the patient's age exceeds the specified age, then C1 = A × P

        • Downgrade: C1 = A × PD

      • If there is not an applicable exception, then C1 = A × P

    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 the Ledger: in the Enter payment dialog box, in the Enter credit adjustment dialog box, and on the Payment tab of the Patient Walkout dialog box. You can click a warning icon to view the details of the exception for the corresponding procedure.

  5. Apply D to calculate the Adjusted Covered Amount (C2).

    Use one of the following calculations:

    • If D > C1, then C2 = 0

    • If D < C1, then C2 = C1 - D

  6. Apply B to calculate I.

    Use one of the following calculations:

    • If C2 > B, then I = C2 - B

    • If C2 < B, then I = C2

    • If B = 0, then I = 0

*For secondary plans:

  • Coordination of benefits rule - The amount paid by all the patient's plans will never exceed the amount that the patient was charged.

  • Non-duplication of benefits clause - Dentrix Ascend does not take into account a non-duplication of benefits clause.

The patient portion is not directly related to the coordination of benefits calculation. When calculating the secondary insurance estimate for a PPO plan, Dentrix Ascend compares the contracted fee in the secondary plan's fee schedule with the entire remaining portion of the charge for the procedure. Because Dentrix Ascend doesn't take into account a non-duplication of benefits clause, the patient's primary and secondary insurance plans can pay up to the full amount of the charge, which could exceed the estimated patient portion (which factors in the lowest contracted fee).

How is the Write-off Adjustment (W) calculated?

Write-off adjustment

The Write-off Adjustment (W) is calculated in the following manner (for PPO plans only):

A represents the Procedure Amount
F represents the Allowed Fee (from the plan's fee schedule)

Use one of the following calculations:

  • If F < A, then W = F - A

  • If F > A, then W = 0

How is the Patient Portion (P) calculated?

The Patient Portion (P) is calculated in the following manner:

A represents the Procedure Amount
W represents the Write-Off Adjustment
I represents the Insurance Portion

  • For a PPO plan, P = A - I - W

  • For an indemnity plan, P = A - I

Note: P includes any D that the patient must pay.

What is the Allowed Fee (F)?

  1. From the Location menu, select the correct location.

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

    The Fee Schedules page opens.

  3. On a location's Fee Schedules page, select a fee schedule.

    The options for editing the fee schedule become available.

  4. Locate the procedure, and look at its fee (under Current Fee).

What is the Remaining Deductible (D)?

  1. On the Patient menu, under Insurance, click (or tap) Insurance Information.

    The patient's Insurance Information page opens.

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

    The options for editing insurance information become available.

  3. Click (or tap) Benefits.

    The Deductibles and Benefits dialog box appears.

  4. Under Deductibles, look at the difference between the Required and Met amounts to determine if a deductible is left.

What is the Remaining Maximum Benefit (B)?

  1. On the Patient menu, under Insurance, click (or tap) Insurance Information.

    The patient's Insurance Information page opens.

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

    The options for editing insurance information become available.

  3. Click (or tap) Benefits.

    The Deductibles and Benefits dialog box appears.

  4. Under Benefits, look at the difference between the Maximum and Used amounts to determine if benefits are left.

What is the Coverage Percentage (C)?

  1. On the Patient menu, under Insurance, click (or tap) Insurance Information.

    The patient's Insurance Information page opens.

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

    The options for editing insurance information become available.

  3. Click (or tap) Coverage Table.

    The Coverage Table dialog box appears.

  4. Locate the correct Code Range for the procedure, and look at the Coverage %.

  5. To view the exceptions for the coverage table, click (or tap) Manage Exceptions.