Assigning alternate benefit codes

You can specify alternate benefit coverage for each insurance profile. (In other words, you can change the benefits for a specific code based on limitations for an insurance profile). The benefits will link to a code's benefit amount and calculate that benefit amount from the allowable amount for the billed code, resulting in a patient portion during billing.

When billing or entering a treatment plan, if the given patient's insurance plan has an Estimator table, the amount of the insurance benefit is calculated from the Estimator table. If the given patient's insurance plan does not have an Estimator table, the insurance benefit amount is calculated based on the percent of the Alternate Benefit Code Fee. In other words, to use alternate benefit codes, the patient's insurance plan must be set up to calculate estimates by a percentage of the fee and not to use the Estimator.

To set up alternate benefit codes

1.   On the Estimates-Percents tab of the Edit Insurance Profile dialog box, click the Alternate Benefits button. This button is available only for indemnity plans (on the General tab of this dialog box, the selected Plan is Indemnity).

The Alternate Benefits dialog box appears.

2.   Double-click in one of the Choose ADA code which has Alternate Benefit fields to paste in an ADA code (from the master fee schedule) for which you want to assign an alternate code. Or, you can type a valid code from the fee schedule.

3.   Double-click in the Choose Alternate Benefit ADA Code field directly below the field from the previous step to paste in the alternate code (from the master fee schedule). Or, you can type a valid code from the fee schedule.

4.   Repeat steps 2 - 3 for any other alternate codes that you want to assign.

5.   Click OK.

Example

The following alternate benefit codes are pre-defined with the upgrade or installation of the program.

Alternate Benefit Codes
Code	002391	002392	004341	002740
Linked Code	002140	002150	001110	002750

If 002391 uses 002140 as an Alternate Benefit Code, the following is assumed:

	Fee	Insurance	Patient
Code 002391	$100.00	$80.00	$20.00
Linked Code 002140	$80.00	$50.00	$30.00

When Billing the 002391, the Allowable amount is $100.00, and the Insurance Portion is drawn from the Insurance Portion for a 002140, which results in a Patient Portion of $50.00.

	Allowable	Insurance	Patient
Code 002391	$100.00	$50.00	$50.00
		002140 Insurance Benefit	Difference between Allowable and Insurance Benefit

 

 

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