Insurance Plans  

To add an insurance plan for a patient, go to the Family module and click Add Insurance in the toolbar. 

If the patient is the subscriber, click Yes. If the patient is not the subscriber, click No. Select the subscriber from the list, or click More Patients to select from the list of all patients in the database. The choices are very clear.

Next, select the insurance plan. You can attach an existing insurance plan, or click New Plan to create a new plan.

This window is divided into four main sections: Patient Information, Insurance Plan Information, Subscriber Information and Benefit Information. 

Patient Information
This area has information that is specific to the patient. In the database, this information is stored in a table called 'patplan'.  The background color is set in Definitions, Misc Colors, Family Module Coverage. The same color is used in the Family module for this information. If you are editing a plan which is not attached to any patient as current coverage, then this upper section might be blank.

Optional Patient ID: This is no longer used by insurance companies in the US. As of 1/1/2012, carriers have generally switched to each patient being their own subscriber rather than having a subscriber ID and a patient ID. This means that you will need to drop some patients from their family's plan and recreate them with subscriber as self, using the patient ID instead of the subscriber ID, although most patients that are tied in with a subscriber will have the same subscriber ID. Do not do this until you are ready to start sending Electronic Claims in 5010 format.

Order: Refers to whether this is primary, secondary, or supplemental insurance. 1 = primary, 2 = secondary, etc. You can change this number at any time.

Pending: Can be used when you have not yet finished verifying insurance, but want to enter insurance anyway. It is informational only, and does not change any functionality of the program. If you want to signify that the patient has insurance, but don't even know the name of the insurance company, create a dummy carrier called 'Pending'. Check this box, then come back later and fix it.

Adjustments to Insurance Benefits: Typically used if the patient has had treatment done at another office this year, or if you have just converted to EZ2000 Plus  Dental. Click Add to adjust benefits for amounts used so far.

Negative numbers are allowed in the Insurance Used field to indicate rollover amounts available from previous year, although it is rare that it is allowed.

If a patient changes carriers or no longer has insurance coverage, click the Drop button in the upper left. Dropping a plan does not delete the plan. It will still appear in the Insurance Plan List and when Plans for Family is clicked under the Add Insurance dropdown.

Insurance Plan Information
This information is specific to the insurance plan. To see insurance carrier changes made to this insurance plan, click Audit Trail.  To select an existing insurance plan, click the Pick From List button.

Any changes made to an insurance plan will usually change the plan for all subscribers. This functionality is dictated by the two radio buttons in the lower right: "Create New Plan if needed" and "Change Plan for all subscribers". The default should normally be Change Plan for all subscribers to prevent spawning of duplicate insurance plans. The default option is set in Family Module Setup, option "InsPlan option at bottom, 'Change Plan for all subscribers', is default". This option should normally be checked.

If you need to create a new plan, select the "Create new Plan if needed" radio button. In order for a new plan to be created, the value must change in one of the Insurance Plan Information Fields on the left side of the screen. If no changes are made, then a new plan will not be created. Changing Benefit Information on the right will not trigger a new plan (with the exception of "benefit year"). Changed benefits are at the plan level and apply to all subscribers.

See below for a description of insurance plan information.

Medical Insurance: Check this box if this is a Medical Insurance plan rather than dental. This box is not normally visible, and must be turned on in Show Features.

Employer: Employer name is optional.

Carrier: Carrier name is required. Click […] to pick an existing carrier from the Insurance Carrier List, or enter carrier information manually.   To print the insurance carrier name and address on an individual mailing label, click Label.

Electronic ID/Payer ID: If the insurance company accepts E-claims, fill in the electronic Payer ID that they give you. To search for a payer ID, click Search IDs.
If the carrier does not accept electronic claims, you have two choices.
1. Leave the Electronic ID blank and submit the claims electronically anyway. If the clearinghouse cannot match the insurance carrier name with a known name, then the claim will be printed by the clearinghouse and mailed.
2. To mail these types of claims, check the Don't Usually Send Electronically box. When Sending Claims, it will be easy to see which claims to print and which ones to send electronically.

Other Subscribers: This field shows the number of subscribers who use this plan. Click the down arrow to see other subscriber names.

Plan Type: There are four choices. See Types of Insurance Plans for more information.
- Category Percentage: for traditional percentage insurance plans.
- PPO Percentage: for Preferred Provider Organizations.
- Medicaid or Flat Co-pay: all categories will be computed at 100% coverage. Disables all other percentages.
- Capitation: for HMO and DMO type plans. Disables all other percentages.

Use Alternate Code: If the insurance plan uses alternate procedure codes, as some Medicaid plans do, check this box to use those codes when submitting claims. Alternate procedure codes are set up in the Edit Procedure Code window.

Don't substitute code (e.g. posterior composites): The substitution codes are set globally in the Edit Procedure Code window. Check this box to enable/disable this feature on this individual plan.

Claims show UCR fee, not billed fee: If you are using Category Percentage type for your PPOs, then you can use this to make your claims show UCR fees.  If you are using PPO Percentage for your PPOs, then there is no need to use this box.  If this insurance is not PPO, there is also generally no need to use this box.

Some insurance companies ask you to submit your UCR (Usual Customary and Regular) fees instead of the fee you actually charged the patient. Check this box to base the billed fee on the the fee schedule of the default Provider. The fee will be clearly visible in the Edit Claim window, and you can still change it manually before sending the claim.

Hidden: Check this box to hide this insurance plan in the Insurance Plan List so it can't be copied for use by other subscribers. If this plan has multiple subscribers, and you want to hide it for all subscribers, you must also select the Change Plan for all subscribers radio button.

Fee Schedule: The fee schedule used by this plan.  If 'none' is the selection, the Provider's Fee Schedule will be used as the default, unless a Patient fee schedule has been assigned.

Claim Form: Select the actual form used to print the claim. It does not affect electronic claims. See Claim Forms for information about importing, adding and editing forms.

Other Fee Schedules: In addition to the regular fee schedule for the insurance plan, there are also two other types of fee schedules: Patient Co-pay and Carrier Allowed. They are described on the Fee Schedules page.

COB Rule: Select a Coordination of Benefits rule option.

Filing Code: If you will be sending e-claims, and the carrier has an Insurance Filing Code, select it.  By default 'Commercial Insurance' is used.  If the filing code is incorrect, then the carrier will reject the claim.

Filing Code Subtype: If the Insurance Filing Code has a specific subtype, select it.

Claims show base units: This usually applies to medical insurance claims only. Check this box to show procedure base units on claims. Base units for procedures are defined in Procedure Code Edit.

Plan Note: Enter notes specific to the insurance plan. This note will show for all subscribers on the plan. To enter notes specific to the subscriber and family members, see the Subscriber Information area.

Subscriber Information
The subscriber is set when first creating the insurance plan. If you need to change the subscriber, click Change.

Subscriber ID: The subscriber's SSN is automatically used as the subscriber ID, but it can be changed since some insurance companies use an alternate number. The Subscriber ID is not allowed to be blank. If the patient has Medicaid, use the Medicaid ID number, then also fill in the Medicaid ID on the Patient Edit window.

Effective Dates: These dates are optional. The end date does not terminate the plan; you must Drop the plan for the plan to not be used.  Set the benefit renewal dates (calendar year or service year) in the Benefit Information section.

Release of Information: Check this box if the patient has signed a form that states that the patient consents to the use and disclosure of protected health information to the insurance company in order to carry out payment activities. If checked, then "Signature on File" will show in box 36 of the claim form.

Assignment of Benefits: Check this box if the patient has signed a form that states that they authorize and direct payment of the dental benefits, otherwise payable to the patient, directly to the dental office. For offices that make patients pay up front, and the insurance checks get mailed to the patient, this box should be unchecked.

Notes: Enter notes specific to the subscriber and associated family members.  These appear in bold red in the insurance grid.

Request Electronic Benefits:   Options are available here if you have set up one of the programs below, and if you have entered a Subscriber ID.
- If you have set up Electronic Benefits, click Request to request benefit information or History to view a history of your requests.
- If you have set up Trojan, the Trojan button, ID field, and Note button will show.  Click Trojan to copy exported Trojan data. Click Note to view benefit notes.
- If you have set up Insurance Answers Plus, the IAP and Note button will show.

Benefit Information
See Benefit Information.