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Columns on the Insurance Plan Screen

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The following columns are in the Insurance Plan details screen:

Standard Plan

  • Code is the five digit ADA code
  • Description is the description of that code.
  • Pri. Fee 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.% 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. indicates the primary deductible. N shows that no deductible is applied to this treatment. Y shows that a deductible will be applied to this treatment.
  • Sec. Fee 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% 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. indicates the secondary deductible. N shows that no deductible is applied to this treatment. Y shows that a deductible will be applied to this treatment.

Participating Plan with Adjustment

  • Code is the five digit ADA code
  • Description is the description of that code.
  • Office Fee 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 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% is the percentage of the P. Allowed/Plan Calculation fee that the insurance plan will cover.
  • Pri ded. indicates the primary deductible. N shows that no deductible is applied to this treatment. Y shows that a deductible will be applied to this treatment.
  • Sec. Fee 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% 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. indicates the secondary deductible. N shows that no deductible is applied to this treatment. Y shows that a deductible will be applied to this treatment.

Capitation Plan

  • Code is the five digit ADA code
  • Description is the description of that code.
  • Pri. Fee 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.% 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. indicates the primary deductible. N shows that no deductible is applied to this treatment. Y shows that a deductible will be applied to this treatment.
  • Pri. UCR% 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 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% 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. indicates the secondary deductible. N shows that no deductible is applied to this treatment. Y shows that a deductible will be applied to this treatment.
  • Sec UCR% 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.

 

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