Adding a coverage table

When used to its full capacity, the coverage table is a powerful tool that allows you to create treatment plan estimates that reflect the actual benefits paid by an insurance carrier.

Most insurance carriers provide patients with a schedule of benefits to declare the maximum annual benefits for the individual and for the entire family. The schedule of benefits also includes deductible amounts, plan maximums, and the percentage of the "usual and customary fee" the insurance carrier will pay. You can add this information to the coverage table.

To add a coverage table

1.   In the Maintenance menu in the Office Manager, point to Reference, and then click Insurance Maintenance.

The Insurance Maintenance dialog box appears.

2.   Select the carrier that you want to add the coverage table to and click Cov Table.

Note: To search for a carrier by name, enter the carrier name in the Enter Carrier Name field. You can also search for a carrier by Employer, Group Plan, Group Number, Local Number, or Address.

The Insurance Coverage dialog box appears.

3.   Under Deductible, type the following deductible amounts:

·        Standard - The deductible that applies to most procedures.

·        Preventive - The deductible if an insurance carrier's coverage has a separate deductible for preventive/diagnostic procedures.

·        Other - The deductible if an insurance carrier's coverage has a separate deductible for specific procedures other than preventive/diagnostic or for procedures not considered standard.

·        Lifetime - The deductible that requires subscribers to pay one deductible for the life of the policy.

·        Annual Individual - The deductible that requires patients to pay a deductible amount each year.

·        Annual Family - The deductible that requires a maximum deductible amount for the entire family each year.

Note: You can assign each range of procedure codes in a coverage table its own deductible type. You can also assign a lifetime, individual, and family deductible to each deductible type. Dentrix calculates the patient portion of charges and adds the appropriate deductible to the patient's payment due.

4.   Type the Annual Maximum Benefit amounts for Individual and Family.

5.   Click the Claim Deadline search button.

The Deadline dialog box appears.

6.   Select the appropriate amount of time allowed by the insurance carrier before pre-treatment estimates or claims expire and will not be accepted.

7.   Click the Select Table search button.

The Select Coverage Table dialog box appears.

Note: Dentrix provides five standard coverage tables that you can modify to fit individual insurance plans. When you add a new insurance plan, Dentrix assigns the first standard coverage table to it automatically.

8.   Select the table most similar to the coverage of the selected insurance plan and click OK.

Dentrix copies the plan. As necessary, you can modify the plan.

Note: If you do not have or know the insurance carrier's schedule of benefits, Dentrix assigns the first standard insurance table to the plan. As you receive payments and make estimates, Dentrix gives you the option to update an insurance plan's payment table automatically. Dentrix stores the dollar amount that each insurance carrier pays by procedure. Dentrix then bases insurance estimates on past payments, making your estimates very accurate.

9.   To group several procedures into categories and assign the percentage the carrier pays, do the following, and then click Add:

·        Beg Proc - Type the beginning code of the procedure code range.

·        End Proc - Type the end code of the procedure code range.

Note: You must use the ADA procedure codes, and you cannot overlap the beginning or ending procedure codes in any range. To assign a single code to a category, make the beginning and end codes the same.

·        Category - Type a name for the procedure code range.

·        Cov% - Type the percentage that the insurance plan pays for the procedures in the code range after any deductibles.

Note: Dentrix estimates 0% coverage for any procedure codes not listed in the coverage table.

·        Deductible - Select a type for the procedure code range.

·        Co Pay - Type the amount the patient pays only if you are setting up a capitation plan.

·        Pre-Est - Select if the insurance carrier requires a pre-estimate for the procedures in the code range.

10. If you are setting up a capitation plan that requires specific co-pay amounts for each procedure, select Co-Payment Calculations for Ins. Portion, and then select one of the following to calculate the amount the insurance carrier will pay:

·        Total Fee x Coverage %

·        (Total Fee - Co-Pay) x Cov %

·        (Total Fee x Cov %) - Co-Pay

11. To create a note documenting an insurance carrier's special requirements or other information, click Notes.

The Insurance Plan Note dialog box appears.

a.   Type the note.

b.   To insert a date, click Insert Dateline.

c.   To perform a spell check, click the spell check button.

d.   Click OK.

Note: You can update insurance plan notes at any time. Insurance plan notes do not print on claims.

12. Click OK. to add the coverage table.