General tab (Edit Insurance Profile)

When adding and editing insurance profiles, use the General tab to set general options for an insurance profile.

· Carrier – Type the insurance company’s name (for example, Metlife, CIGNA, or Aetna).

Note: This is a required field.

· Employer – Type the group or employer’s name (for example, Starbucks or Dillards). For DMO plans, you can enter a plan name (for example, Plan L or Plan M for Aetna DMO plans).

Note: This is a required field.

· Group – Type the group number (if applicable for the employer or group).

Important: You CANNOT use a carrier and employer combination more than once.

· If an insurance carrier offers both dental and medical plans, to distinguish between the two, they should have different carrier names (for example, Cigna and Cigna Medical).

· If an employer offers more than one plan, you must distinguish the plans in the employer name (for example, Starbucks Incentive 80% and Starbucks Incentive 90%).

· Plan – Select a plan type based on how the office handles the insurance NOT on what type of plan the insurance company states they are (for example, if the plan being entered is a PPO plan, but the office does not participate with the PPO plan, select “Indemnity” as the plan type). Changing the plan type here changes the way the software functions for the plan. The following plan types are available:

· Indemnity – The program charges a patient the amount from the default fee schedule (according to the fee schedule hierarchy). It then estimates the insurance portion based on the estimate amount in the estimator table OR the percentage specified on the Estimates - Percents tab for the plan.

Select this plan type if either one of the following is true:

· You DO NOT participate with the insurance plan.

· You DO participate with the plan BUT want to write off the difference between the charged fee and the contracted fee when an insurance payment is posted.

· PPO – The program charges a patient the contracted (allowable) amount from the estimator table for the plan or for the UCR group. It then estimates the insurance portion based on the estimate amount in the estimator table OR the percentage specified on the Estimates - Percents tab for the plan. However, if the procedure code does not exist in the estimator table, the program charges the patient the amount from the default fee schedule (according to the fee schedule hierarchy) and calculates the insurance estimate based on the percentage specified on the Estimates - Percents tab for the plan.

Note: If the procedure code exists in BOTH the estimator table for the plan AND the default fee schedule for either the plan, the provider, or the patient’s PIC or patient type (according to the fee schedule hierarchy), the software charges the lesser of the two amounts.

Select this plan type if all of the following scenarios are true:

· You are a participating provider for this plan.

· You want to enter the insurance contracted rates.

· You want to charge the patient based on the contracted rates entered.

PPO plans usually pay based on a percentage of the contracted rate but can be set up to estimate insurance portions based on a set amount.

· DMO – The program charges a patient based on the contracted amount and the estimated insurance and patient portions from the estimator table for the plan. However, if the procedure code does not exist in the estimator table, the program charges the patient the amount from the default fee schedule (according to the fee schedule hierarchy). The patient is responsible for the full amount, and the estimated insurance portion is zero.

Select this plan type if all of the following scenarios are true:

· You are a participating provider for this plan.

· You want to enter the contracted rates and estimates and charge the patient based on the contracted rates.

· The plan’s portion is based on set fees instead of percentages.

· For any procedure code that is not set up, the patient is responsible for paying the full amount.

· Managed Care – The program charges a patient the contracted amount from the estimator table for the plan. The patient is responsible for paying the contracted amount in full, and the estimated insurance portion is zero. This type of plan is usually a discount plan where a claim is not sent to the insurance company.

Select this plan type if all of the following scenarios are true:

· You are a participating provider for this plan.

· You want to enter the contracted rates.

· The patient is responsible for the full amount of the contracted rate (there is NO insurance reimbursement).

· Medicaid – The program charges Medicaid the fees set up in the master fee schedule. The estimated insurance portion is 100%. The estimated patient portion is 0%.

Select this plan if you are a participating provider for Medicaid, you want to charge the insurance carrier the Medicaid contracted rates, and there is ONLY ONE Medicaid plan.

Important: If a Medicaid plan has different fees for patients who are less than 21 years old and more than 21 years old, set up the plan as a DMO plan instead of as a Medicaid plan.

· Address – Type the address where claims should be mailed to the insurance company. You do not need to type the name of the insurance company name here again.

Note: These fields are required even if you send claims electronically.

· Contact – Type any contact information that you have for the insurance company (for example, “Option 2 for eligibility”).

· Location – Select the location that you want to attach the profile to. If you have more than one location, you should attach ALL profiles to location 1 so that all locations have access to the full list of profiles.

· Type – Select the type of plan:

· Dental – If this is a dental plan.

Important: You must have a dental form selected next to Form link on the Claims (basic) tab for the plan.

· Medical – If this is a medical plan.

Important: You must have a medical form selected next to Form link on the Claims (basic) tab for the plan.

· Claim Type/CMS-1500 Type – Select a claim type. The options that are available depend on whether this is a dental or a medical plan.

· We participate with this plan – For dental plans, this is informational only, but you can select this check box if your office participates with this plan. For medical plans, select this check box if your office does accept assignment for this plan in Box 27 of the CMS medical claim form.

· Phone – Type the insurance company’s phone number.

· Fax – Type the insurance company’s fax number.

· Email – Type the insurance company’s email address.

· Pt Type – Select the patient type that you want to have assigned to a patient automatically when the insurance profile is attached to a patient.

Note: The patient type is attached to a patient only if the plan is that patient’s primary insurance coverage.

· Comments – Type any additional plan information that applies to ALL patients with this plan (for example, “Pano covd 1/60mos” or “3mo waiting period for OS”).

Fee schedule hierarchy

· The default fee schedule is determined by the following fee schedule hierarchy (from highest to lowest precedence):

· Patient type (highest precedence)

· PIC

· UCR group

· Profile

· Provider (lowest precedence)

The default fee schedule applies to all plan types, including indemnity.

Need more help?

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