Insurance Estimating Formulas

MacPractice calculates the portions of charges based on the following formulas:

[Fee] - [Allowed] = [Write Off]
If you participate with the plan, the estimated write-off will stay in the Insurance Portion until the insurance payment is entered or the claim is manually closed. If Participate is not checked in the insurance plan reference, the estimated write-off will be placed in the patient portion.

The calculation for the insurance portion can vary, depending on whether you have Flat Rate Coverage enabled for the selected code.

For percentage coverage:
([Allowed Amount] - [Deductible] - [Copay]) x [Insurance %] = [Insurance Portion (up to the patient's remaining coverage)]

For flat rate coverage:
[Allowed Amount] - [Deductible] - [Copay] = [Insurance Portion (up to the patient's remaining coverage or the flat rate, whichever is less)]

When using plans, information entered within the plan overrides the Company Info and Provider IDs tabs whenever the plan is associated to the account.

If you are using EOB columns to send secondary eClaims, the disallowed amount in the insurance payment window is calculated based on the following formula:

[Fee] - [Paid] - [Sum of the EOB Columns Deductible, Coinsurance and Copay] = [Disallowed amount]

Any remaining Disallowed amount requires a corresponding Reason Code. If the Disallowed amount is zero, no additional Reason Code is required.

Deductible and Copay amounts will be added to the Patient Portion.

If any variables are not correctly set up, delete the charge and reenter it after corrections are made to recalculate the insurance estimate. You can also recalculate the estimate by checking and unchecking the Patient Responsible checkbox in the charge window if a payment has not been applied to the charge.

Secondary Insurance Estimating Formulas
Secondary insurance coverage is calculated differently depending on whether the Coordination with Other Carriers is set to Standard or Non-Duplicating:

Standard Coverage = Secondary allowed (x) Insurance % (-) Secondary Deductible (=) Secondary Insurance Portion (up to the Secondary Remaining Coverage and/or Unpaid Amount)

Non-Duplicating Coverage = Secondary allowed (x) Insurance % (-) Secondary Deductible (=) Secondary Insurance Portion (+) Primary Insurance Portion (up to the Secondary Remaining Coverage, and/or Unpaid Amount)

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