Insurance Information |
The Insurance Plan List contains each insurance plan used by any of your patients.
Quick Steps
Repeat these steps for each insurance plan covering your patients.
Full Instructions Click Setup in the toolbar, locate the Accounting Setup section, and click Enter insurance plans. You can also click the Lists menu and select Insurance Plan List.
Press F8 or click New Insurance Plan.
General tab The General tab contains demographic and insurance plan information, as well as insurance claim options.
Enter all demographic information for this insurance company. Leave the Code field empty and let the program create a unique identifying code, or create your own. If a particular insurance company offers several plans that are used in your practice, create a different record for each plan.
Click if this is a Medical Insurance Plan.
In the Group Name box, enter the group name of the patient's plan. This is often the patient's employer's name.
In the Employer field, locate and enter the patient's employer name. If the employer record has not yet been created, click the Employer field and press F8 to create the record "on the fly." When you save the employer record, that name is displayed in this field. This field is often left blank.
In the Group Number field, enter the plan's group number.
The Local field is not often used. If your patient is a member of a Union, enter the Union Number in this field.
The Fee Schedule field connects this insurance carrier to a specific fee schedule. This is the fee schedule that contains the amounts you have agreed the insurance company will pay you for procedures. If you choose the correct fee schedule here, you can run Day Sheets at the end of the day and get an accurate accounting of how much money you actually made that day. Do not confuse this field with the Fee Schedule on Claim field in the next section.
The Payer ID field contains the electronic claim routing number. This is provided by the insurance company.
Select the type of insurance in the Insurance Type box.
The Category field is an extra place provided for printing purposes. Add a user-defined category here and you can filter reports by this field.
If you are sending electronic claims, be sure to click Send Electronic Claims.
In the Patient ID to use (Box 15) [of the ADA 2003 form], choose the format requested by the insurance company.
In the Info for Claim (Box 48) [of the ADA 2003 form] field, choose whether you want provider or practice information displayed in Box 48 of the claim form. If the whole office is credentialed under the practice name, use the practice information.
In the Provider Pin Used on Claim (Box 54) [of the ADA 2003 form] field, choose which number you want displayed in Box 54 of the claim form.
In the Fee Schedule on Claim box, choose the fee schedule that contains the amounts you usually charge for your services, not the Fee Schedule you've agreed on with the particular insurance company. This is for billing purposes only. The reason for this is because insurance companies sometimes increase their coverage amounts and don't inform you promptly. If the insurance company decides to pay more for a procedure and you bill at the lower rate, you will only receive the lower rate. By using the fee schedule containing your usual charges here, the insurance company will adjust the amount and send its current rate, and you will always receive the correct payment.
In the Billing Provider ID (Box 49) [of the ADA 2003 form] box, select the type of ID to send. Usually the insurance company tells you which to use. The actual information is contained in IDs tab of the Provider record. See Provider Information.
In the Billing SSN or TIN (Box 51) [of the ADA 2003 form] field, choose the TIN or Social Security Number. If your practice is a corporation or a limited liability corporation, the IRS has issued it an EIN (or TIN). Choose that here. If your practice is a sole-proprietary company, you might want to use the provider's Social Security Number.
If appropriate, click the Do Not Bill Insurance box or the Do Not Bill Patient box. For example, if your patient has Medicaid coverage, you will click Do Not Bill Patient.
In the Default Payment Code and Default Adjustment Code fields, choose your default payment and adjustment codes. These will be entered automatically when transactions are created.
Insurance Notes - Enter frequencies and a run down of benefits here. These are especially helpful when making recall appointments, as these notes are displayed at that time. You can see quickly how soon procedures can be scheduled for the next appointment and still be covered.
Coverage tab This tab is important because all fee schedules are filtered by the information in this tab to determine patient responsibility. This tab displays patient deductible information and coverage percentages received from the insurance company, and indicates the method used to calculate the insurance portion.
Enter patient deductible information here. Sometimes there is a deductible for an individual and one for the family. Also there can be deductibles for different types of procedures.
Next set the Deductible Reset Month. Usually this is January of each year.
If the insurance plan has maximum benefit amounts, enter them in the Max Individual Benefit and Max Family Benefit fields. This is helpful to know in case someone has some expensive procedures to be performed. The patient may want to put some of the work off until next year, when the maximum individual or family amounts are renewed.
In the Insurance Estimate Calculation box, choose the method of insurance calculation. Most often you will use the default method of insurance calculation, (Total Fee - Co-Pay) x Coverage %.
To get a company's coverage percentages, you might be able to access an insurance company Web site. Most likely you are going to have to call the company directly and get the information over the phone. You need to get frequencies and coverages: how often a certain procedure can be performed and still be covered (like X-rays and cleanings), and what percentage of a particular type of procedure is covered by the insurance plan or how much of a deductible is required, as well as maximum coverage, etc.
You can enter the insurance plan's coverage percentages here in the grid or load the Default Coverage Entry screen. If you have already entered information in the Default Coverage Entry screen, it can be copied here by clicking Load Default Coverage. See Default Coverage Tables.
Click Save Changes or press F3.
Customizing The columns displayed in the Insurance Plan List screen are customizable. See Customizing a Screen.
In addition, the filters can also be changed -- added to, removed, etc. See Customizing Filters.
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