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Insurance Estimating - Configuration

Insurance Estimating is set up by first establishing procedure types, which are then associated to specific codes in the Fee Schedule and insurance company Plan tab. Next, the Insurance Estimating Preference is enabled and plans can be associated to patients.

The Insurance Estimating Configuration Guide contains the following sections:

Procedure Types
Procedure Types are defined by insurance companies, but are generally universal across most carriers. Some example Procedure Types include Diagnostic, Restorative, Preventive, Labs, Radiography, and so on.

Add the Procedure Types in References > Procedure Types with the plus button in the sidebar and save each record.


If the Localization Preference Use Canadian Claim Fields has been enabled, the Procedure Type Reference will also include a CDA Code field.

In MacPractice DDS, designate a Procedure Type as a Dental Procedure Type or an Orthodontic Procedure Type within the Reference. Procedures associated to a Dental Procedure Type will reduce the Remaining Coverage field as they are estimated, while procedures associated to an Orthodontic Procedure Type will reduce the Orthodontic Remaining Coverage as they are estimated.

The common Procedure Types for Medical and Dental codes are listed below. Each insurance plan may use different percentage amounts and types. Additional Procedure Types may be added for the variations of individual insurance plans.

Medical

  • Anesthesia (00100-01999; 99100-99140)
  • Surgery (10021 to 69990)
  • Radiology (70010 to 79999)
  • Pathology and Lab (80047 to 89398)
  • Medicine (90281 to 99199 and 99500 to 99607)
  • Evaluation & Management (99201 to 99499)
  • HCPCS (A0000 to Z9999)
Dental ADA
  • Diagnostic (D0100-D0999)
  • Preventative (D1000-D1999)
  • Restorative (D2000-D2999)
  • Endodontics (D3000-D3999)
  • Periodontics (D4000-D4999)
  • Prosthodontics, Removable (D5000-D5899)
  • Maxillofacial Prosthetics (D5900-D5999)
  • Implant Services (D6000-D6199)
  • Prosthodontics, Fixed (D6200-D6999)
  • Oral and Maxillofacial Surgery (D7000-D7999)
  • Orthodontics (D8000-D8999)
  • Adjunctive General Services (D9000-D9999)

Dental CDA

  • Diagnostic (00011-05201)
  • Radiographs, CBCT (07011-07043)
  • Preventative (11101-16519)
  • Restorative (20111-29319)
  • Endodontics (33221-39313)
  • Prosthodontics, Removable (51101-57402)
  • Prosthodontics, Fixed (62101-69812)
  • Oral and Maxillofacial Surgery (71101-79962)
  • Orthodontics (80601-89301)
  • Adjunctive General Services (91121-99555)
Note: Procedure Types are separate from Procedure Categories, which are used to track production through the Production by Procedure Category report. As an internal tool, Procedure Categories may set up to track different types of restoration procedures, new patient visits versus established patients, and so on.

Fee Schedule
Associate each code in the Fee Schedule to the correct Procedure Type in References > Fee Schedule > Fee. Select each code from the code table and set the Procedure Type within the Procedure Type menu. Repeat the process for each Fee Schedule if multiple Fee Schedules are used.


The Update Fee Schedule Database Utility can associate each code in a Fee Schedule to a specific Procedure Type at once. Procedure Types can also be associated to a code from the charge window, however setting the correct Procedure Type for each code in the Fee Schedule can prevent an erroneous Procedure Type association, which may result in estimation errors each time the code is entered.

Plans
Insurance company plans are set up within References > Insurance Companies > Plans. Click the plus button to create and rename a new plan. Plan names are used to identify different plans as they are assigned to patients with an insurance company. Typically, plans are named for the employer or plan name.


The Plans tab contains a series of sub-tabs in which the variables for the patient's specific plan are entered. These sub-tabs are documented below.

Coverage
The Coverage tab contains many fields which will be used as variables within Insurance Estimating calculation.

  • Annual Coverage: Enter the amount of coverage the plan provides the patient. If the patient does not have a set amount of annual coverage, or the annual coverage is unknown, enter an amount larger than a year of procedures.
  • Max Ortho Benefit (MacPractice DDS only): Enter the amount of orthodontic coverage the plan provides for the patient. This field is similar to the Annual Coverage field, except Ortho coverage is only reduced by charges associated with an Orthodontic Procedure Type.
  • Annual Deductible: Enter the plan's annual deductible. If a deductible is entered, the patient is responsible for all charges until the deductible is met.
  • Participate: This checkbox indicates provider plan participation (as set in the Participate tab) and overrides the settings in Insurance Company > Provider IDs. If the provider participates, any fee amount greater than the allowed amount is written-off.
    • If all providers participate with the plan, it will be checked
    • If none participate, it will be unchecked
    • If participation varies, the checkbox will have a dash. Set participation in the Participate tab.
  • Start Date: Enter the date coverage starts for this plan. This will populate to the Start Date field in the Primary or Secondary tab when the plan is added to a patient's record.
  • End Date: Enter an expiration date, when applicable. This will populate to the End Date field in the Primary or Secondary tab when the plan is added to a patient's record. This field should be left blank unless the coverage ends on a specific date.
  • Renewal Date: Enter the date the plan benefits will renew. The renewal date entered in the Primary or Secondary screen will override this date.
  • Deductible Applies To: This tab specifies how the deductible should be calculated.
    • Each: Each patient will incur the deductible before coverage begins.
    • 1: The first patient who pays the deductible will activate coverage for the remaining patients on the account.
    • 2: When two patients cover the deductible, coverage is enabled for everyone in the account.
    • Accumulative: Any patient on the account may reduce the deductible to zero. Once the deductible is reduced to zero, plan coverage begins.
    • Lifetime Deductible: Once the deductible has been met, it will not be renewed.
  • Coordination With Other Carriers: Coordination with other carriers can be standard or non-duplicating.
    • Standard Coverage: The secondary carrier will cover the percentage another carrier has paid up to the total allowed.
    • Non-Duplicating Coverage: The secondary carrier's coverage is only calculated from the percentage left unpaid by the primary insurance. The secondary carrier pays only the difference between what the primary carrier actually paid and what the secondary carrier would have paid if it had been the primary carrier.
Within the Procedure Type table, add the expected percentage of coverage for each procedure type in the % Insurance Pays column. The field will automatically update to the format %/x, where "%" is the percentage of coverage and "x" is the remainder of 100%. Check the Applies to Deductible checkbox if a charge of this Procedure Type should decrement the Annual Deductible.
 
Contact the insurance carrier to obtain information for the patient and plan. The plan's annual deductible and annual coverage in the Insurance Company reference are used as the default when a plan is associated to a patient. If there is a difference between the patient's deductible and remaining coverage and the Plan's annual deductible and annual coverage, enter the patient's copay, deductible, and remaining coverage in Patient > Insurance within the Patients ability.

Demographic
Within any insurance plan, the Demographic tab may be used to enter a separate address to which claims can be sent if the address for this plan is different from what is listed under the Company Info tab. The address on the Plan Demographic tab will override the address on the Company Info tab if a plan is set for the patient.

Tip: Many offices leave the address blank within the Company Info tab and instead use the Plans > Demographic tab to eliminate multiple references for the same insurance carrier.

Participate
The Participate tab lists all providers along with a Participate Plan checkbox. In multiple provider circumstances with varying participation, the Participate Plan checkboxes in the Participate tab can be used rather than the Participate checkbox in the Coverage tab, which applies to each provider.

Participation set within the Plans tab will override participation set on the Provider IDs tab.


Allowed
The Allowed Amount is the amount the insurance carrier allows for a procedure. The Coverage Percentage in the plan will calculate the insurance portion based on the allowed amount.

Within the Procedures tab, Allowed amounts for each procedure code (fee) may be added according to the patient's unique plan. Add procedure codes to the list individually with the plus button, or select the Add from Fee Schedule item from the Update Fees menu to add all procedure codes from a selected Fee Schedule. Add the Allowed and Work RVU amounts within the columns for each code.


The Update Fees menu lists additional items which may be used as alternatives to manually entering each code.

  • Add From Fee Schedule: This item imports procedure codes from a selected Fee Schedule, mapping the amount of the fee as the allowed amount. If a carrier's fee schedule is used to establish fees, the allowed amounts and fee amounts may be the same. Any code for which the fee amount is not equal to the allowed amount for that plan can be adjusted after the fee schedule codes are imported.
  • Copy Allowed: This item imports allowed amounts from another plan. Plans for an insurance company may have the same allowed amounts, despite different coverage or deductibles. Set up the allowed amounts within one plan, select the plan to populate with the allowed amounts, then select the Copy Allowed From Selected Plans option.
  • Delete Allowed Amounts: This item clears all allowed amounts.
Allowed amounts can also be added to plans as Insurance Payments are made.

Flat Rate
Flat rate coverage is an assumed coverage for selected codes unless allowed amount or remaining coverage are exceeded. Flat rate settings override percentage coverage. Click the plus button next to the flat rate table, then enter the code and rate within the fields to add each code individually. To copy the flat rate information to or from another plan, or add the flat rate from a fee schedule, choose the item from the Update Flat Rate Amount menu.


To remove a flat rate, select it within the table and click the minus button. To remove all flat rate items in a selected plan, use the Delete All Flat Rate item in the Update Flat Rate Amount menu.

As with allowed amounts, flat rate coverage amounts can be added to the plan as Insurance Payments are entered.

Flat rates are not to be confused with allowed amounts covered at 100%. For example, vision coverage may pay for frames based on a flat rate system. If a patient purchases a $300 pair of frames, a $250 flat rate will allocate $50 to the patient portion whereas an allowed amount covered at 100% will allocate $50 to the insurance portion and assumed a write-off.

Preferences
Insurance Estimating is enabled in Preferences > Insurance. Check the Use Insurance Estimating checkbox to enable the feature.


Check the Assume 100% coverage for patients who have no insurance plan configured checkbox if Insurance Estimating is not to be configured for all patients and Insurance estimating will not be used for patients with no insurance plan. This is useful for when you do not have all the plan information for a carrier.

Check Assume 100% coverage on charges with no procedure type to assume a carrier will pay a charge when the procedure type is unknown.

Patient Plan
The plan is selected in the Primary or Secondary tab in the Patient Account. Use the Plan menu to select a plan. If the patient does not have a plan, select None in the Plan menu, or double-click on the insurance company and check the Patient has no plan checkbox within the Plans tab.

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