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Insurance Plan List – Creating a new Group Plan

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To create a new Group Plan from the Group Plan List, click on the New    icon.

When the New Group Plan window opens, the program will automatically open the Insurance Company List, where you must choose the Insurance Company that is offering this plan.  (If you search for the Insurance Company on the Group Plan List prior to clicking the New icon, or if you came to the Group Plan list via the Insurance Company List when linking to an Employer, the Insurance Company will be preselected)

The Group Plan Information window is broken down into two tabs, General and Details.


(Click image for full size)

The fields of information/options on the General tab and what they represent are:

  • Insurance Company
    • As mentioned earlier, each group plan is connected to the providing insurance company. Note: this is only editable when creating a new group plan. Once a plan has been created, it will always be linked to the same insurance company.
  • Group Number
    • Group number is required for insurance patients. If you do not have the group number when creating the group, it is recommended for you to enter two dollar signs ($$) followed by the plan name or other abbreviation.  If you leave this field blank, MOGO will assign a generic group number for you, which will start with “$$DEFAULT” followed by a random number. Note: You can always come back to the Group Plan information window and edit this information at a later time.
  • Plan Name
    • The plan name field is optional and will not be indicated on any claim forms.  MOGO recommends you use this field for identification purposes.  For example, if the group plan is the Gold plan offered via XYZ insurance company for ABC employer you could use the Plan Name: ABC employer – Gold plan.
  • Insurance Form
    • MOGO has several paper claim forms available for filing insurance claims, including: the 94, 2000, 2002, 2006, and 2012 ADA forms; the Ohio Medicaid form; the Denti-Cal and Denti-Cal 2007 forms, and the Attending Physician’s Report.  There is also the ability to file insurance claims electronically.  The form you choose under the Insurance Form field is what we be the default claim form for patients with this plan. You always have the option of changing the form when filing a claim, but this setting determines the default.
  • Payment Type
    • There are three payment types to choose from:
      • Payment to Provider – When the insurance company sends payment for the claim, they will remit it to the office.
      • Payment to Patient – When the insurance company sends payment for the claim, they will remit it directly to the patient.
      • Blank – This payment type is used for all paper claim forms.  It requires both the patient and/or responsible party to sign off approval of the claim.
  • Plan Type
    • There are four types of plans that can be created within MOGO:
      • Standard Plan
        • This is the standard type of group plans you can choose from.  A standard type plan will  calculate benefits based on four factors
          • PRI/SEC Fee – The amount the Insurance Plan dictates you are allowed to charge the patient.  If this amount is lower than your UCR fee the treatment’s fee will automatically be adjusted to the PRI/SEC Fee. Note: A write-off for the adjustment is not added to the transaction screen, the Fee amount is simply changed.
          • PRI/SEC Coverage Percentage – The percentage of the PRI/SEC Fee or your UCR fee that the insurance company will cover.
          • PRI/SEC Maximum – The maximum amount the insurance company will cover for the service code.
          • PRI/SEC Deductible – Individual treatment can be designated to apply a deductible for the patient.
      • Capitation Plan
        • A Capitation type plan works in nearly the exact same way as a standard plan with the addition of a PRI/SEC UCR Percentage field which is a percentage of the office’s usual fee. This amount will be added to the patient’s co-payment.
      • Percentile Reimbursement PPO
        • This plan is ONLY applicable for offices in the state of Hawaii.  If you are not providing services in the state of Hawaii DO NOT select this plan type.
      • Participating Plan with Adjustment
        • A participating plan w/ adjustment works similarly to a standard type plan, but is based on different criteria
          • Office fee – this is your UCR fee.
          • PRI/SEC Approved/Accepted fee – This is the amount the insurance plan dictates you are allowed to charge the patient. If this amount is different from your Office/UCR fee the difference will show as the patient’s responsibility but MOGO will automatically add an adjustment code to write off the difference amount.
          • PRI/SEC Allowed/Plan Calculation Fee – This is the amount the insurance plan calculates benefits off of.  If the Allowed/Plan Calculation fee is different from the Approved/Accepted fee, the difference will be added to the patient’s responsibility.
          • PRI/SEC Coverage Percentage – The percentage of the Allowed/Plan Calculation fee that the insurance company is expected to pay.
          • PRI/SEC Deductible – Individual treatment can be designated to apply a deductible for the patient.
  • Pre-Authorization
    • If the group plan specifies that it needs a pre-authorization you would mark this option Yes. If the group plan specifically states that it does not require/accept pre-authorizations you would mark No. If it does not specify, you will mark None.  None is the most common selection for this setting, as it lets you decide whether to do a pre-authorization or not.
  • Remark 1 & 2
    • These boxes allow you to enter in notes for the group plan.
  • Apply percentage of deductible equal to coverage percentage
    • This option dictates how deductibles are applied to the patient.  With it checked, the deductible amount will equal that service code’s coverage percentage. For example: if the service code is set to apply a deductible, and has a coverage percentage of 75%, and the deductible amount entered is $50, with this option checked off the amount the program will apply for deductible will be $37.50.  If it is not checked off, the deductible amount applied will be $50.
  • Apply deductible after insurance benefits are calculated
    • With this option checked, MOGO will calculate the percentage of coverage of your fee and then subtract the remaining deductible. If unchecked, the benefits will be calculated after the deductible is applied. For example: If the Fee is $100, the Cov % is 80, and Ded is $50 – with this option checked, the Transaction screen will read: FEE=$100, EST INS=$30, DED=$50, EST PAT=$70. If unchecked, the Transaction screen will read: FEE=$100, EST INS=$40, DED=$50, EST PAT=$60)
  • Use my office fees, but calculate benefits from the plan fee schedule (if available)
    • This option should be marked off for standard plans that pay a percentage of their own fee schedule, regardless of the actual fees submitted. It allows you to specify insurance plan fee schedules while still using your UCR fees. This will cause your UCR fee to show in the Fee column on the Transaction screen but the estimated insurance coverage will be based on the plan fee, coverage percentage, and maximums. The difference between your UCR fee and the Plan Fee will be added to the patient’s responsibility.
  • When Sending insurance claims to this plan, submit charges from
    • For Standard and Capitation plans that do not have the “Use my office fees, but calculate benefits from the plan fee schedule” option checked off, this choice dictates what fees show on insurance claims. If the calculate benefits option is checked off, or if the plan is a Participating w/ Adjustment, this option is not applicable. Note: this setting does not effect estimated insurance or patient balances, it simply affects the fees shown on the insurance claims.
      • The Transaction Screen
        • With this option selected, the fees that show on the insurance claim will mirror the fees on the Transaction screen.  For example: If your UCR fee is $100 but the Plan Fee is $85, the Transaction screen will show $85 in the Fee field.  This is what will show on the insurance claim.
      • Office Fee Schedule (UCR)
        • With this option selected, the fees that show on the insurance form will always be your UCR fees. For example: if your UCR fee is $100 but the Plan Fee is $85, the Transaction screen will show $85 in the Fee field.  The insurance claim, however, will still show the $100.
      • The option selected in Office Setup
        • The Insurance Tab in Office Setup contains this same setting, which is the default when creating new plans.  If you would like all plans to be consistent, you can leave this option selected and the setting in Office Setup will be applied.
  • Coordination of benefits calculation method
    •  This setting is applicable only if this group plan is assigned to a patient as secondary insurance.
      • Standard
        • The Standard COB method calculates coverage based on the remaining amount after primary insurance has paid. For example: If the total fee is $100 and primary insurance pays $75, the secondary insurance would calculate based on the coverage percentage of the remaining $25. So if secondary also pays 75% it would estimate coverage to be $18.75.
      • Non-Duplication
        • The Non-Duplication COB method calculates coverage based on the original fee amount. This causes the secondary insurance to cover significantly less (in general) than the Standard method.  For example: If the Total fee is $100 and primary insurance coverage percentage is 75% they would pay $75.  Secondary insurance would only pay if the coverage percentage is higher than primary, and they would pay the difference.  If the coverage percentage for the secondary insurance is the same or lower than primary, they would not cover the amount remaining after primary insurance pays. In our example, if secondary insurance coverage percentage is 80% they would pay the difference between what they would have paid and what primary did pay (75% of $100 is $75 | 80% of $100 is $80 | secondary insurance would pay the $5 difference).
      • The option selected in Office Setup
        • The Insurance Tab in Office Setup contains this same setting, which is the default when creating new plans.  If you would like all plans to be consistent, you can leave this option selected and the setting in Office Setup will be applied.
  • Renew Date
    • The month and day when insurance coverage resets for this group plan.
  • Covered Until (age)
    • The age in which children/students can be covered until under this plan. Note: These fields are for your records only. MOGO will not remove coverage for patients after they reach a certain age.
  • Individual
    • Annual Coverage
      • The total amount the plan will cover for the year.
    • Annual Deductible
      • The amount the patient must cover each year before the plan will cover treatment.
    • Ortho Max
      • The maximum amount each year the plan will cover for orthodontic treatment. Note: This field is for your records only.
  • Family
    • Annual Coverage
      • The total amount the plan will cover for additional family members for the year. Note: This field is for your records only.
    • Annual Deductible
      • The amount the entire family must cover each year before the plan will cover treatment. Note: This field is for your records only.
    • Ortho Max
      • The maximum amount each year the plan will cover for orthodontic treatment for the family. Note: This field is for your records only.
  • Fee Schedule
    • The fee schedule template is created on the New Insurance Company setup. A template can be chosen from the drop down list and the details of the template can be viewed by clicking the “…” button.

 


(Click image for full size) (This screenshot is of a Standard-type plan)

The fields of information/options on the Details tab and what they represent change depending on the plan type selected.

Standard Plan

  • Code
    • The service code, pulled directly from the office’s service code list.
  • Description
    • The service code’s description, pulled directly from the office’s service code list.
  • PRI. Fee
    • This is the amount the insurance company dictates patients who are covered by this plan as their primary insurance can be charged. If the PRI. Fee is less than your UCR fee, the PRI. Fee will be automatically adjusted on the patient’s transaction screen. If your UCR fee is less than the PRI. Fee there will be no adjustment on the transaction screen and your UCR will be displayed. If the insurance company/plan does not specify a fee, this field will be left blank ($0.00) and coverage will be based on your UCR fee.
  • PRI. Cov.(%)
    • This is the percentage of the PRI. Fee/UCR fee the insurance company says they will cover if this is the patient’s primary insurance plan. If the insurance company/plan does not specify a percentage this field can be left blank and the transaction screen will estimate primary insurance to pay 100% of the PRI. Fee/UCR fee.
  • PRI. Max.
    • This field is used on its own or in conjunction with the PRI. Cov.(%).  A dollar amount entered in this field represents the MAXIMUM amount the insurance plan will pay for the treatment if this plan is designated the patient’s primary insurance plan.  If the PRI. Cov.(%) field is left blank and a percentage is entered in the PRI. Max. field, the insurance plan will pay 100% of the PRI. Fee/UCR fee up to the amount specified in PRI. Max.. If there is an amount in the PRI. Cov.(%) field and an amount is entered in the PRI. Max. field, the insurance plan will pay that % of the PRI. Fee/UCR fee up to the amount specified in PRI. Max..
  • PRI. Ded.
    • This field will contain either an “N” or a “Y”.  This dictates whether the treatment will apply the annual deductible when added to the transaction screen or not, if this plan is assigned to the patient as primary insurance.
  • SEC. Fee
    • This is the amount that coverage is calculated off of when this plan is assigned to a patient as secondary coverage. Unlike PRI. Fee, this will not adjust the fee column in the transaction screen, it is simply what secondary coverage is based off of.  If left blank ($0.00) secondary coverage will be calculated off of the UCR fee.
  • SEC. Cov.(%)
    • This is the percentage of the SEC. Fee/UCR fee the insurance company says they will cover if this is the patient’s secondary insurance plan. If the insurance company/plan does not specify a percentage this field can be left blank and the transaction screen will estimate secondary insurance to pay 100% of the SEC. Fee/UCR fee.
  • SEC. Max.
    • This field is used on its own or in conjunction with the SEC. Cov.(%).  A dollar amount entered in this field represents the MAXIMUM amount the insurance plan will pay for the treatment if this plan is designated the patient’s secondary insurance plan.  If the SEC. Cov.(%) field is left blank and an amount is entered in the SEC. Max. field, the insurance plan will pay 100% of the SEC. Fee/UCR fee up to the amount specified in SEC. Max.. If there is a percentage in the SEC. Cov.(%) field and an amount is entered in the SEC. Max. field, the insurance plan will pay that % of the SEC. Fee/UCR fee up to the amount specified in SEC. Max..
  • SEC. Ded.
    • This field will contain either an “N” or a “Y”.  This dictates whether the treatment will apply the annual deductible when added to the transaction screen or not, if this plan is assigned to the patient as secondary insurance.

Capitation Plan

  • Code
    • The service code, pulled directly from the office’s service code list.
  • Description
    • The service code’s description, pulled directly from the office’s service code list.
  • PRI. Fee
    • This is the amount the insurance company dictates patients who are covered by this plan as their primary insurance can be charged. If the PRI. Fee is less than your UCR fee, the PRI. Fee will be automatically adjusted on the patient’s transaction screen. If your UCR fee is less than the PRI. Fee there will be no adjustment on the transaction screen and your UCR will be displayed. If the insurance company/plan does not specify a fee, this field will be left blank ($0.00) and coverage will be based on your UCR fee.
  • PRI. Cov.(%)
    • This is the percentage of the PRI. Fee/UCR fee the insurance company says they will cover if this is the patient’s primary insurance plan. If the insurance company/plan does not specify a percentage this field can be left blank and the transaction screen will estimate primary insurance to pay 100% of the PRI. Fee/UCR fee.
  • PRI. Max.
    • This field is used on its own or in conjunction with the PRI. Cov.(%).  A dollar amount entered in this field represents the MAXIMUM amount the insurance plan will pay for the treatment if this plan is designated the patient’s primary insurance plan.  If the PRI. Cov.(%) field is left blank and a percentage is entered in the PRI. Max. field, the insurance plan will pay 100% of the PRI. Fee/UCR fee up to the amount specified in PRI. Max.. If there is an amount in the PRI. Cov.(%) field and an amount is entered in the PRI. Max. field, the insurance plan will pay that % of the PRI. Fee/UCR fee up to the amount specified in PRI. Max..
  • PRI. Ded.
    • This field will contain either an “N” or a “Y”.  This dictates whether the treatment will apply the annual deductible when added to the transaction screen or not, if this plan is assigned to the patient as primary insurance.
  • PRI. UCR.(%)
    • This is the percentage of the UCR fee that will be applied to the patient’s responsibility as a co-payment when this plan is designated as primary coverage.
  • SEC. Fee
    • This is the amount that coverage is calculated off of when this plan is assigned to a patient as secondary coverage. Unlike PRI. Fee, this will not adjust the fee column in the transaction screen, it is simply what secondary coverage is based off of.  If left blank ($0.00) secondary coverage will be calculated off of the UCR fee.
  • SEC. Cov.(%)
    • This is the percentage of the SEC. Fee/UCR fee the insurance company says they will cover if this is the patient’s secondary insurance plan. If the insurance company/plan does not specify a percentage this field can be left blank and the transaction screen will estimate secondary insurance to pay 100% of the SEC. Fee/UCR fee.
  • SEC. Max.
    • This field is used on its own or in conjunction with the SEC. Cov.(%).  A dollar amount entered in this field represents the MAXIMUM amount the insurance plan will pay for the treatment if this plan is designated the patient’s secondary insurance plan.  If the SEC. Cov.(%) field is left blank and an amount is entered in the SEC. Max. field, the insurance plan will pay 100% of the SEC. Fee/UCR fee up to the amount specified in SEC. Max.. If there is a percentage in the SEC. Cov.(%) field and an amount is entered in the SEC. Max. field, the insurance plan will pay that % of the SEC. Fee/UCR fee up to the amount specified in SEC. Max..
  • SEC. Ded.
    • This field will contain either an “N” or a “Y”.  This dictates whether the treatment will apply the annual deductible when added to the transaction screen or not, if this plan is assigned to the patient as secondary insurance.
  • SEC. UCR.(%)
    • This is the percentage of the UCR fee that will be applied to the patient’s responsibility as a co-payment when this plan is designated as secondary coverage.

Participating Plan w/ Adjustment

  • Code
    • The service code, pulled directly from the office’s service code list.
  • Description
    • The service code’s description, pulled directly from the office’s service code list.
  • Office Fee
    • This is the Office (UCR) Fee for the service code.  Note: This field pulls directly from the Service Code List and is not editable.
  • P. Approved/Accepted
    • For a Participating Plan w/ Adjustment, the difference between what the plan dictates you can charge and your UCR fee is written off as an adjustment.  The P. Approved/Accepted amount is where you will enter the amount the plan dictates you can charge. The difference between your UCR fee and the P. Approved/Accepted fee will be added to the patient’s responsibility and the program will automatically add a write off for this amount and apply it to the patient balance.
  • P. Allowed/Plan Calculation Fee
    • This is the amount that the plan will calculate benefits off of.  The difference between the P. Allowed/Plan Calculation fee and the P. Approved/Accepted fee will be added to the patient’s responsibility.
  • PRI. Cov.(%)
    • This is the percentage of the P. Allowed/Plan Calculation fee that the insurance plan will cover.
  • PRI. Ded.
    • This field will contain either an “N” or a “Y”.  This dictates whether the treatment will apply the annual deductible when added to the transaction screen or not, if this plan is assigned to the patient as primary insurance.
  • If a plan designated as a Participating w/ Adjustments is assigned to a patient as secondary insurance, it will behave like a standard plan.  The adjustment function of this plan type is only applicable when it is assigned as a primary insurance.
  • SEC. Fee
    • This is the amount that coverage is calculated off of when this plan is assigned to a patient as secondary coverage. Unlike PRI. Fee, this will not adjust the fee column in the transaction screen, it is simply what secondary coverage is based off of.  If left blank ($0.00) secondary coverage will be calculated off of the UCR fee.
  • SEC. Cov.(%)
    • This is the percentage of the SEC. Fee/UCR fee the insurance company says they will cover if this is the patient’s secondary insurance plan. If the insurance company/plan does not specify a percentage this field can be left blank and the transaction screen will estimate secondary insurance to pay 100% of the SEC. Fee/UCR fee.
  • SEC. Max.
    • This field is used on its own or in conjunction with the SEC. Cov.(%).  A dollar amount entered in this field represents the MAXIMUM amount the insurance plan will pay for the treatment if this plan is designated the patient’s secondary insurance plan.  If the SEC. Cov.(%) field is left blank and an amount is entered in the SEC. Max. field, the insurance plan will pay 100% of the SEC. Fee/UCR fee up to the amount specified in SEC. Max.. If there is a percentage in the SEC. Cov.(%) field and an amount is entered in the SEC. Max. field, the insurance plan will pay that % of the SEC. Fee/UCR fee up to the amount specified in SEC. Max..
  • SEC. Ded.
    • This field will contain either an “N” or a “Y”.  This dictates whether the treatment will apply the annual deductible when added to the transaction screen or not, if this plan is assigned to the patient as secondary insurance.

If a fee schedule template has been assigned to the plan, the coverage details have only limited editing capabilities.  You will be able to update the coverage percentage and the deductible fields, but for the Fee(Standard)/Approved(Part. w/ Adj.) and the Max(Standard)/Allowed(Part. w/ Adj.), as well as adding new codes, you will need to modify these through the Fee Schedule Template editing screen.

To add new codes and their coverage details for a plan that does not have a fee schedule template assigned, you have a few choices.  You can copy from another insurance plan, either the entire plan or specific information (such as the fee schedule, plan maximums, and/or payment percentages); manually enter service codes by typing directly into the bottom open Code field and filling out the coverage details; or you can copy all service codes from your service code list.

  • From another insurance plan
    • If you copy from another insurance plan you can choose to copy the entire plan (including all fees, maximums, percentages, and deductible information) or to pick specific information to bring over.
  • Manually entering
    • Manually entering your coverage details can be quite tedious and can lead to errors, so MOGO recommends you only do this when you need to enter in only a few codes.
  • Copy Code
    • By clicking Copy Code, the entire service code list will be imported onto the coverage details for this plan.  You will enter any and all information you have for the plan and it’s codes and click Done.  Any codes you do not edit will be removed from the list.

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