Insurance Benefits  

In the Edit Insurance Plan window, there is a section at the lower right that stores the plan benefits. These percentages and amounts are used to calculate Treatment Plan Insurance Estimates.

Note:  If you change insurance benefits, all Claim Procedure estimates will also change, including those on current and sent claims.

Every benefit is stored as a row in the database, because this is exactly how information comes in from the insurance companies as the dental industry gradually moves to electronic benefit requests. This will save you huge amounts of time, and allow you to have accurate real time benefit information on demand without making any phone calls.

To enter benefit information, double click anywhere in the Benefit Information grid.

Benefits apply to all subscribers of the plan.  If different subscribers have different benefits, create different Insurance Plans.

Simplified View: In order to show this view, at least one of each E-Benefit Category in Insurance Category Setup must be present (Accident, Crowns, Diagnostic, Endodontics, General, MaxillofacialProsth, OralSurgery, Orthodontics, Periodontics, Prosthodontics, Restorative, RoutinePreventive, and DiagnosticXRay).  This box usually is checked, unless you are in a foreign country and not using the typical American settings.

Benefit Year:  Determines the renewal date used to calculate benefits and applies to all benefits in the window.  Check Calendar if the insurance plan follows the calendar year (starts in January; ends in December).  Uncheck the box if the insurance plan follows a service year that starts in a month other than January.
Then, in the Month field enter the two-digit month when benefits renew (e.g. October = 10, February = 02).

Annual Max/Deductibles:  Enter all your amounts, individual and family, keeping in mind that leaving a box blank is not the same as entering a zero. Blank indicates that the amount is unknown. If you leave the Annual Max blank, then no calculations of Treatment Plan Insurance Estimates can be done. 

Fluoride to Age: Uses the code D1208.  Now that codes D1203 and D1204 are obsolete, this part of the program is less annoying.

Frequencies: Enter plan frequency limitations.  Frequency limitations are for information only; they are not calculated in Treatment Plan Insurance Estimates. 

Ortho:  Enter Orthodontic lifetime maximums and percentages.  The Ortho max is separate from the General annual max as long as the Insurance Category Spans are set correctly.  The correct setup (and default) is to have an Ortho span of D8000 to D8999 and to exclude that span from the General category.  The Treatment Plan Module Insurance section is for the General category only; ortho calculations will not show there.

Categories:  Enter the percentages of coverage for each category.

Other Benefits:  You can usually ignore this list.  Other Benefits are useful when dealing with incentive plans, if you need to add a benefit that is not considered preventative, major or minor, or if you are using Open Dental in a foreign country.  See Other Benefits below.

Notes:  Certain types of benefits are not easily codified, so they do not yet have a box. These types of benefits are just entered as subscriber notes for now. Examples of benefits which get entered as notes are:
- Missing tooth exclusion (a clause that states that if a tooth was extracted before the patient became insured through them, that they will not cover any replacement teeth including a partial or a bridge).
- Wait on major treatment (usually 6 months to a year).

Other Benefits
Other Benefits are useful when dealing with incentive plans, if you need to add a benefit that is not considered preventative, major or minor, or if you are using Open Dental in a foreign country.  Some examples are listed below.

• Override a procedure or category benefit percentage for a particular patient but not everyone on the plan. This can be necessary when you have an incentive plan, and each family member is at a different percentage.
• Cover a particular procedure at a different percentage, outside of the normal categories. For instance, you want nitrous oxide to not be covered (0%), even though other procedures in that Insurance Category would be covered at 50%.
• You have different categories (usually this means you are not in the United States of America) so you do not have the category entry boxes in the main benefit area. In this case make an entry for each of your self-defined insurance categories.
• Some preventive work does not apply toward regular annual max.  Examples include CHIP and a number of Medicaid plans.  Another example is a plan that has a limit of $150 for xrays for the year, with everything else covered at a flat co-pay amount.  In all of these cases, you will need to add a benefit with an annual limitation for a certain category.
• Set different annual maximums for each family member. Add an "other" benefit for each family member. Set Category as None, Type as Limitations, and Coverage Level as Individual.  Select the Time Period, enter the annual maximum in the Amount field, and check the Patient Override checkbox at the top.

To add an Other Benefit, click Add.

Patient Override:  Check this box if this is an incentive plan benefit where each family member is at a different percentage.  These benefit changes will only affect this patient and this plan.  No other patient will be affected.

Category:  Insurance category or procedure code this benefit applies to.

Type: Some types affect Treatment Plan Insurance Estimates; others are informational only.
- ActiveCoverage: informational only
- CoInsurance: affects estimates
- Deductible: affects estimates
- CoPayment: informational only
- Exclusions: informational only
- Limitations: affects estimates

Percent:  The percentage of coverage for this category or procedure code.

Amount: The dollar amount that is covered for this category or procedure code.

Time Period:  Some options affect in Treatment Plan Insurance Estimates; others are informational only.
- Service Year: affects estimates
- CalendarYear: affects estimates
- Lifetime: information only
- Years: information only

Quantity/Qualifier:  If there is a frequency limitation on a category or procedure, enter a number and select the qualifier that matches.  Benefits that have frequency limitations are not calculated in Treatment Plan Insurance Estimates.

Coverage Level: 
- Individual: Apply this benefit change to all individual subscribers on this plan.
- Family: Use when a family has a benefit that is in addition to the individual coverage of the subscriber (e.g. individual preventative benefit is $250 per year, but the family has a total cap of $500). This is used when specific categories of coverage have specific limits.

Per-Visit Co-Pay
Especially with Medicaid, a patient may be required to make a co-pay per visit rather than per procedure.  Follow these steps to automatically calculate the co-pay amount.
1. Create a non-D Procedure Code called office visit, or something similar, and select the checkbox "Do Not Usually Bill to Insurance".
2. Set up a co-pay Fee Schedule.
3. On the Edit Insurance Plan window, select the new co-pay fee schedule in the Patient Co-pay Amounts dropdown. 
4. Add a fee to the Procedure Code for both the insurance fee schedule and for the co-pay fee schedule.
5. Add the office visit procedure code to each scheduled Appointment for patients with this insurance.
Feature Request #2073 would make this process take less steps.

Benefit Calculation Logic
Advanced users might be interested in the Benefit Calculation Logic.