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Insurance Estimating - Portion Troubleshooting

Portion Troubleshooting
With Insurance Estimating correctly configured, portions are calculated using the Insurance Estimating Formulas and Insurance/Plan Configuration as the charge is entered. If a data entry error has caused an erroneous portion, use the troubleshooting guide below to find the source of the issue, then delete and reenter the charges on the same day (Posted Date) to avoid conflicts with accounting reports.

For information on portion troubleshooting when Insurance Estimating is not used, please view the Troubleshooting Guide within the Ledger documentation.

The flow chart below was designed to portion troubleshoot in summary, however more detailed explanations can be found in the following documentation.

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  • Insurance Preferences: Preferences may affect insurance portions if no procedure type or plan is set. Charges may be estimated to 100% insurance coverage, however deductible and copay amounts will still be the patient's responsibility. These charges are not truly "estimated" per se, and can be controlled with claim statuses.
  • Verify the patient has an enabled insurance and plan: Estimation will not be accurate if the insurance plan is not properly set up. A patient with no insurance will only have a patient portion. If no procedure type or insurance plan is set, no estimate will be made.
  • Verify the charge has an associated Procedure Type: If no procedure type is set, you should be able to pick one on the fly, and the plan estimates will be applied to the procedure instantaneously.
  • Verify the patient has remaining coverage: Annual coverage from the plan applies to the patient by default as Remaining Coverage when the plan is associated to the patient. This remaining coverage amount will decrement as procedures are entered until the amount reaches zero or the renewal date. Treatment plan estimates will also apply to the remaining coverage amount when treatments are entered, however the treatment plan doesn't affect the displayed remaining coverage amount until the treatments have been moved to transactions. If the remaining coverage amount is zero, click Refresh Remaining Coverage from the patient's Insurance tab to recalculate the coverage from the plan information, or manually override the coverage amount.
NOTE: If the remaining coverage or deductible amount are manually overridden, the Refresh Remaining Coverage button will not work. Refresh Remaining Coverage always uses the plan coverage and deductible amounts to recalculate the patient's coverage, and will not consider any manually overridden amounts.
  • Charges apply to the patient's copay: The table at the bottom of the Charge window will display patient responsible amounts in the Copay or Deductible fields. The copay amount is pulled from the patient's Insurance tab > Copay field if the Charge Copay checkbox is checked in the Charge window. If charges always require a copay, this can be checked in the fee schedule. If the copay amount entered on the patient's Insurance tab is zero, the copay amount will be zero. However, having the checkbox checked makes the field editable.
  • Charges apply to the patient's deductible: Deductible amounts are pulled from the patient's Insurance tab > Deductible field. Charges will apply to the deductible as long as the Applies to Deductible checkbox is checked next to the Procedure Type on the insurance plan. The deductible amount can be set on the plan and overridden on the patient's Insurance tab or in the Charge window.
  • Procedure allowed amount: Insurance Estimation calculation is based on the allowed amount for the procedure rather than the total fee amount. If participation is enabled within the plan, the write-off portion is calculated from the fee minus the allowed amount and this amount will remain in the insurance portion until the actual write-off amount is entered with the Insurance Payment. If participation is not enabled in the plan, any amount over the plan's allowed amount will be in the patient portion. Allowed amounts will pull from the Insurance Plan > Allowed amount for the code. If the code uses modifiers within the fee schedule, use separate allowed amounts for the code and the modified code. If no allowed amount is saved in the plan, the allowed amount is assumed the same as the fee amount.
  • Coverage percentage amount: In the New Charge window, this amount is the Pri Ins % field for primary coverage and the 2nd Ins % field for secondary coverage. The amount is set on the plan per procedure type. The insurance coverage percentage amount is multiplied by the allowed amount minus any deductible or copay to determine the insurance portion.
  • Flat rate rather than percentage: If the Insurance Portion in the charge window is listed in blue, the charge is a flat rate charge, and will not be affected by percentage amounts. If a code has a flat rate amount entered in References > Insurance Companies > Plans > Flat Rate, the insurance portion will equal the flat rate amount, up to the patient's remaining coverage or the code's allowed amount (as set in the Allowed tab of the Plans reference).
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