Pre-authorization estimates

In Dentrix, insurance estimates are based on different factors. The first factor is the actual fee posted for the procedure, which is based on the fee schedule you assign to the patient. The second factor is the way you set up the coverage table. The third factor is whether there is any information entered in the payment table. The final factor is whether the patient has met any of their deductibles and/or their maximum in their insurance benefits. This topic discusses each of these factors individually and then illustrates how insurance estimates are calculated in Dentrix.

Fee schedules

With a fee schedule, you can enter the dollar amount a patient is charged for a specific procedure. You can attach a fee schedule to patients in three ways:

·        Through their Family File

·        Through the insurance they are attached to

·        Through their primary provider

The patient’s family file is first checked for a fee schedule. If a fee schedule is not attached, the insurance plan is checked. If the insurance plan does not have a fee schedule attached to it, the fee schedule attached to the patient’s primary provider is used.

Important: Because the provider is at the bottom of the fee schedule hierarchy, you must attach a fee schedule to the provider in the Provider Information dialog box.

The coverage table

You can use the coverage table to enter how much an insurance plan pays for a particular procedure or group of procedures. You can also modify any coverage table entries relevant to the insurance plan. You set up coverage tables in the Family File.

The payment table

Using the payment table, you can enter the dollar amount the insurance plan pays for specific procedures. As payments come back from the insurance, you can update the insurance coverage. The actual payment information is stored in the payment table. Therefore, you can add procedures to the payment table manually, or you can have Dentrix do it for you when you post a payment to a claim.

Patient insurance benefits

Many times patients come to your practice after using some or all of their insurance benefits. In order to calculate insurance estimates properly, you must enter this information into the patient’s account.

How Dentrix calculates insurance estimates

The flow chart demonstrates the steps taken when a procedure is posted to determine the estimated insurance portion:

When a deductible is applied to a procedure, two formulas are used to calculate the insurance portion:

·        If the procedure is not in the payment table, the following formula applies: Insurance Portion = (Procedure Fee – Deductible) x Coverage Percent

·        If the procedure is in the payment table, the following formula applies: Insurance Portion = Payment Table Amount – (Deductible x Coverage Table Percent)

Important: To figure out the patient portion, subtract the insurance portion from the procedure fee.

For example, if the patient is going to have an amalgam done for $250 with a $50 deductible and the insurance covers 80%, the insurance portion is calculated using the first formula. The insurance portion is:

·        Insurance Portion = ($250 – $50) x 80% = $160

Whereas, if the patient is going to have an amalgam done for $250 with a $50 deductible and the insurance covers 80%, but the payment table shows the insurance usually pays $180 for the procedure, the insurance portion is calculated using the second formula. The insurance portion is:

·        Insurance Portion = $180 – ($50 x 80%) = $140