Depending on the view options selected on the View menu and view options selected in the Insurance/Case Amounts section, Treatment Planner can include insurance estimates in the case details and Insurance/Case Amounts section.
Insurance estimates are calculated using the following process:
Any deductibles to be applied to the treatment plan are calculated.
Dentrix Enterprise looks at the first procedure in the list and subtracts the deductible amount from the cost of the procedure and applies it to the patient portion. Any remaining amount is then included in the insurance estimate.
After applying the deductible amount, Dentrix Enterprise looks at each remaining procedure being displayed:
If the procedure has an entry in the payment table that indicates a specific dollar amount the insurance company will pay for the procedure, Dentrix Enterprise uses that amount as the insurance estimate for the procedure.
If the payment table does not contain a figure, Dentrix Enterprise then references the coverage table to find the percentage of the fee the insurance company covers. That percentage is then included in the insurance estimate.
Note: When setting up the insurance coverage table from Family File, you can flag certain procedures as requiring pre-authorizations. Treatment Planner will automatically place an "N1" or "N2" (depending on whether the primary or secondary insurance requires pre-authorization) in the Pre-Est column (if being viewed) when a procedure requiring pre-authorization is part of the treatment plan.
The following example illustrates the calculation method:
A patient has a $50 deductible to be applied. The patient has a root canal at $500 and a crown at $613 treatment planned. The coverage table states that both procedures will be covered by the insurance at 50%.
To calculate the insurance and patient portions, Dentrix Enterprise first applies the deductible amount to the largest procedure (the crown, at $613) by subtracting the deductible ($50), equalling $563. The coverage percentage of 50% is applied to this ($563 x 50%), making the estimated insurance portion $281.50. The patient portion for this procedure would be the original fee minus the estimated insurance portion ($613 - $281.50), or $331.50.
Then, Dentrix Enterprise figures the next procedure, the root canal. No payment table entry exists, so Dentrix Enterprise uses the coverage table to figure the insurance portion for the root canal ($500 x 50% = $250). The patient would owe the remaining portion, which is also $250.
The two insurance portions are added, and the insurance estimate results in ($281.50 + $250 = $531.50). The patient would owe the remainder, which is ($331.50 + $250 = $581.50).
Note: For a plan where a co-payment is required, the patient's portion usually equals the co-payment; it is never less than the co-payment. The insurance portion equals either the payment table amount or the coverage table amount. The insurance portion plus the patient portion is never greater than the total charges. If it is, then the program will subtract from the patient's portion. Medical insurance is not used when calculating insurance estimates.