How to Add an Insurance Plan
Summary:
Insurance plans can be entered into the system by employer or insurance company
Steps:
1. Click the Insurance menu on the toolbar and select Add/Edit Plans, or click File > Update > Insurance > Add/Edit Plans.
The Insurance Plan Information window appears.
2. Click Add Plans.
The Create New Insurance Plan ID dialog appears.
3. Type a unique ID for the plan you are adding, keeping in mind the following:
- Try to enter an abbreviated version of the actual name of the plan. For example, a company plan for Toys R Us, might be setup with a plan ID of " TRU"., or an insurance company such as Canada Life might be set up as CANLIFE. Other offices like to use alpha-numeric abbreviated names, such as GUWL55555 for plan number 55555 covered by Great West Life.
- You can enter Plan ID "UNKNOWN" to indicate that the patient has secondary insurance coverage, but the details of the plan are unknown.
- Do not use spaces in Plan IDs. For example, use LIBERTYMUTUAL but not LIBERTY MUTUAL.
- Do not use dashes in the plan ID.
- Maximum 8 characters are allowed as a Plan ID.
4. Click OK.
The new insurance Plan ID is added to the Plans list. The next step is to enter the information for the plan.
5. Type the name of the plan in the Plan Name field.
6. In the Group or Plan No. field, do one of the following:
If entering an Employer plan, type the group number for the insurance plan. All patients assigned to this plan will automatically assume this group number.
If entering an Insurance company plan, leave this field empty and enter the group number for each individual patient on their Insurance tab. See
7. In the Division/Sect No. field, do one of the following:
If entering an Employer plan, type the division or section number for the insurance plan level. All patients assigned to this plan will automatically assume this division or section number.
If entering an Insurance company, leave this field empty and enter the division or section number field directly on the patient’s Insurance tab.
The next step is to enter the name of the Insurance carrier to whom the plan belongs.
8. In the Insurance Co. ID field, do the following:
a. Click the Select/Edit Carrier button.
The Insurance Carrier File Update window appears.
b. Click on the applicable insurance carrier in the Insurance Carriers list.
c. Click OK. The name of the Insurance carrier is now shown in the Insurance Co. ID field.
9. In the Take Assignment check box, do one of the following:
Click this check box if your office will take insurance assignments for any patient on the plan you are adding.
Leave the check box blank, if your practice will never take insurance assignments for the plan you are adding.
You should select Take Assignment for every plan, unless you’re absolutely sure your office won’t take assignments for any patient.
10. In the Manual Estimates check box, do one of the following:
- Leave the check box blank if you want ABELDent to calculate the amount the insurance plan your adding will cover when a procedure is billed.
- Click the check box if you DO NOT want ABELDent to calculate the amount the insurance plan your adding will cover when a procedure is billed.
11. In the Notes and Line 2 fields, type any comments that are relevant to the insurance plan you’re adding.
12. In the Age Rule field, type the rule that specifies patients of different age groups have different coverage policies.
Entering an Age rule means you do not have to manually check each patient's age and ensure that the coverage is under the correct plan. For example, suppose the ABC insurance plan defines three age groups:
- 0 to 12 years
- 13 to 16 years, and
- 17 years and over
Each of these age groups requires a different coverage policy (special schedule). The Age Rule allows you to enter the same Plan ID for each patient using this coverage regardless of age. You no longer have the responsibility of manually keeping track of each patient's age and when you should change him/her to another plan because of age.
To use this function, set up three insurance plans representing the age groups as follows:
- ABC (for 17 years and older)
- ABC12 (for 0 to 12 years old)
- ABC16 (for 13 to 16 years old)
You should enter the following in the Age Rule field on the ABC plan as follows:
AGE:0-12=ABC12 AGE:13-16=ABC16
If the patient is:
- 0 to 12 years of age, ABELDent will use the ABC12 plan.
- 13 years of age, ABELDent will switch to the ABC16 plan.
- 17 years of age, ABELDent will switch to the regular ABC plan.
Important: To avoid errors, do not enter information in the Age Rule field except for what is intended. For example, do no enter miscellaneous notes.
13. The Ortho Age and Ortho Student Age fields are for reference purposes only and are not used in any calculation.
- In the Ortho Age field, type the age to which this insurance plan covers patients who are not students for orthodontic dentistry. This information is for reference purposes only. ABELDent does not use it in any calculations.
- In the Ortho Student Age field, type the age to which this insurance plan covers patients who are students for orthodontic dentistry.
14. If the plan you’re adding requires a non-standard claim form, enter the form ID in the Assigned Form ID field. The ID you enter must correspond with a Form ID on the Insurance Forms File Update dialog box and on the Doctor's Form Information Update screen. The Standard Dental Claim form will be used if you leave this field blank.
15. Click the Skip Statement check box if you DO NOT want ABELDent to print a statement for patients with this plan. For example, you probably would not print statements for those patients with Social Service plans.
16. Click the Print Estimate on Receipt check box if you want ABELDent to print estimates of what the insurance plan will cover on the patient's account statement for patients with this plan.
17. In the Signature Required field, do one of the following:
- Type "Y" in the Signature Required text box if the patient must sign this insurance form.
- Type "N" if you have the patient’s signature on file. ABELDent will print "Signature on File" in the appropriate place(s) on the insurance form.
The signature you obtain and place on file may or may not be recognized as a legal signature by insurance companies. Check with the patient’s insurance carrier before using this feature.
18. Click the Requires Diagnostic Code check box if the insurance plan you’re adding requires a diagnostic code in order to process a claim.
19. Click the Exclusive Coverage check box, if the services and procedures covered under the insurance plan will not be submitted to any other plans.
20. Click the down-arrow in the Plan Type field and select the type of plan you are adding:
C - Capitation
Q - RAM-Q
V - Veterans
A - NFLDMC-PMP - Provincial Medical Plan
N - NIHB - Non-Insured Health Benefits for First Nations and Inuit
21. If this insurance plan uses a fee schedule that differs from the Master Fee Schedule your practice is currently using, you can replace the amount charged to patients covered by this plan with the amount expected from the insurance company. Click the down-arrow beside Replace Fee? and select one of the following options from the list.
Replace Fee Field Options:
| Replace Fee field Options | Replace Fee field Descriptions |
| Y | ABELDent will replace the fee the practice charges with the amount the insurance plan covers (except when the coverage is 0.00) |
| N or leave blank | ABELDent will charge the amount in the Master Fee Schedule |
22. The Schedules Charge field is used to select the name of the Special Fee Schedule that the office will charge. When this field is left blank ABELDent will simply default to charge the fees found in the Master Fee Schedule.
To charge out other fees:
i. Click the down-arrow beside Charge to view a list of existing Special Fee Schedules.
ii. Click on the Special Fee Schedule you want to be used for charging and ABELDent will charge out fees from that special fee schedule instead.
23. The Schedules Coverage field is used to select the name of the Special Fee Schedule that this insurance plan will pay.
To select the Special Fee Schedule:
i. Click the down-arrow beside Coverage to view a list of existing Special Fee Schedules.
ii. Click on the Special Fee Schedule you want to be used for billing under the coverage.
24. A Copay rule sets a fixed payment amount for which the patient is responsible. In order to use a Copay rule, you must ensure that a Special Copay Fee Schedule has been setup in the Special Fee Schedule file of ABELDent.
To select the Copay Special Fee Schedule:
i. Click the down-arrow beside Copay to view a list of existing Special Fee Schedules.
ii. Click on the Special Fee Schedule that ABELDent should use to adjust the amount that appears in the Paying text box on the Payment Received dialog box. This adjustment takes place to ensure that the patient pays the fixed amount specified by the Copay Schedule.
Note: When updating the insurance plan and specifying fee schedules, ABELDent will warn you
26. Use the SC/RP field to track the scaling coverage limit in a patient’s insurance plan by Rolling Period or Calendar years. ons.
27. When a scaling contact (SC) is auto-created by the system, a warning message will appear indicating the number of scaling units allowed for the rolling period and the number of scaling units remaining. Click for sample.
The scaling limits set for the plan are also shown on the patient’s Insurance tab.
28. Click the month and day buttons to select the Anniversary (beginning) date for the plan’s deductibles and maximums. The anniversary date is used to determine whether to apply maximums or deductibles to the patient’s account. If you do not choose a date, ABELDent will assume an anniversary date of January 1st.
29. If applicable, enter the Carry Over months for the deductible. Some insurance plans will apply the deductible paid in one year to work done in the next year if the dental visit is close to the anniversary date of the insurance plan.
30. Record the Classes of coverage in the plan as follows:
(P)reventive - Enter the percentage allowed for all preventive procedure codes. ABELDent picks the usual range of procedure codes that are classed as preventive.
(B)asic - Enter the percentage allowed for all basic procedure codes. ABELDent picks the usual range of procedure codes that are classed as basic.
(M)ajor - Enter the percentage allowed for all major procedure codes. ABELDent picks the usual range of procedure codes that are classed as major.
(O)rtho - Enter the percentage allowed for all orthodontic procedure codes. ABELDent picks the usual range of procedure codes that are classed as orthodontic.
You will notice that by entering the required percentages in the Classes category, the corresponding percentages in the detailed category listing will be updated accordingly.
31. This area provides a detailed breakdown of percent coverage associated to procedure code ranges. The chart below shows the associated procedure code range for each class:
| Class (Name) | Class (Type) | Default Procedure Code Range (associated with this class) |
| Diagnostic | P | 01000 - 09999 |
| Preventative | P | 10000 - 19999 |
| Restorative | B | 20000 - 26999 |
| Major Restorative | M | 27000 - 29999 |
| Endodontics | B | 30000 - 39999 |
| Periodontics | B | 40000 - 49999 |
| Removable | M | 50000 - 59999 |
| Fixed | M | 60000 - 69999 |
| Simple Extractions | B | 70000 - 71999 |
| Surgery | M | 72000 - 79999 |
| Orthodontics | O | 80000 - 89999 |
| Adjunctive See **NOTE | N | 90000 – 99999 |
32. A Note field is provided to enter special coverage details related to specific categories. Click here for example:
| PrPreventive | P | 80% | 13101 to 13110 not covered - 0% |
33. Click the Details button if you want to customize the default procedure code range or specific codes within the range. See for information. If you do not set up insurance coverage for a plan, ABELDent assumes the plan covers 100% of the charged fee.
The category of Adjunctive defaults to a 'Class' of N (indicating NO associated Class) and a 'Pays' of 0%. The procedure code range associated with the Adjunctive category is 90000 to 99999. Note, that this is the range where lab codes fall into (99111). Therefore, ensure that this category is updated to reflect the correct Class AND Percentage allowed for by this plan. (Hint: generally Lab is considered M-Major). If the Adjunctive category is NOT updated, ABELDent will NOT be able to calculate lab coverage in assignment offices and will NOT deduct lab from the insurance maximums and will not place the lab fee on the assigned balance. Note: You should also be entering a fictional dollar value into the Master Fee Schedule for lab procedure codes. In the Master Fee Schedule, go to lab codes and enter a 'Normal Additional Fee' of $1000.00. This fee will appear in the billing screen whenever entering in lab services and will be edited as required. ABELDent will then be able to recalculate the coverage according to the rules setup in the detailed coverage information section.
Product (s): ABELDent
Category: Insurance
Classification: Public
Date Created: 28 April 2016
Created by: Brian Neale