Benefit Logic
This
page describes the logic used to calculate benefits. It is
extremely technical and not to be used by persons without knowledge on
how to
Kinds of Benefits
There are about 6 different kinds:
Limitation Amount: Maximums, Ortho Lifetime maximums, family, individual, fluoride.
CoInsurance %: For all, for Category, or for one procedure. A matching patplan % always wins over a plan %.
Deductible: General, or for Category. Even for procedure. Family or individual.
Exclusions: example, cosmetics not covered. $0 coverage
CoPayment: This is handled in fee schedules instead of in Benefits. DO NOT USE.
Limitation for time period: Exams per year, etc. These
are never included in calculations. They may be transferred to
the recall system in a future version.
Benefit Types used by EZ2000Plus Dental Software
ActiveCoverage: Not usually used. Would only be used if you are just
indicating that the patient is covered, but without any specifics.
Percentage: aka CoInsurance.
Deductible: Dollar amount.
CoPayment: DO NOT USE.
Exclusions: Services that are simply not covered at all.
Limitations: Covers a variety of limitations, including max, frequency, fee reductions, etc.
Timing of Calculations
Insurance estimate calculations are very complex, so they are only
calculated at specific times. These estimates are
calculated at the following specific times:
Viewing the Treatment Plan module. (all procedures for the patient)
Adding a new procedure.
Editing a procedure.
Creating a claim. (the procedures on the claim)
Deleting a claim.
Closing the edit procedure window.
Heirarchy
Benefits are calculated on a single procedure at a time. This
procedure has a specific procedure code, and only benefits which apply
to that code are considered. There can be multiple benefits
all applying to a single code. As long as they are of
different kinds, then there is no ambiguity. But if they are of
the same kind, then a heirarchy needs to be considered. From
broadest to most specific:
No Category
Category, top to bottom.
Single procedure.
Lower, more specific items in the list always take priority over broader ones higher up if they are of the same kind.
Awareness of other Procedures
Even though benefits are calculated on one procedure at a time, there
frequently comes a moment in the calculation when it is necessary to
know about benefits applied to other procedures. The time span can be
large, and information may be needed about multiple patients. For
example, an ortho lifetime max needs to know about all procedures,
regardless of how long ago they were performed. And a family
maximum can require knowledge of procedures from all other family
members.
When considering other procedures, completed procedures that
have been attached to claims are always considered, whether the actual
payment or just the estimated payment. For TP procedures,
only those that come "before" the current procedure are
considered. The order is as displayed in the TP module.
The internal mechanism for obtaining information about other
procedures is as follows. Before starting the calculation, a
single query is used to grab a list of objects. Each object
contains a date, proccode, ins paid/est, and deductible paid/est.
The list contains information from all completed procedures attached to
claims as well as adjustments to insurance benefits contained
within InsPlans. To keep the list shorter, a date range is
calculated first based on the information in the list of
benefits. Also, other family members are only included if there
are family level benefits. Family members are defined as other
patients with the same insurance plan, whether actually in the family
or not.
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