Specify Benefit Plans

Important: Given the complex nature of benefit plans, we do not recommend adding benefit plans from the Patient Info window > Insurance tab. We recommend that your institution disable all fields in the Insurance tab except for the Link to Insurance Benefit Plan () icon so that only users with insurance permissions can create benefit plans. Even then, we recommend you add plans via the Maintenance module to prevent benefit plan duplicates.

The Insurance tab contains fields related to the patient’s insurance plans(s). This includes the benefit plan information such as the insurance provider, employer, coverage details, patient payment details, and policy information, such as subscriber details and family balance.

A benefit plan provides coverage for a variety of medical and dental procedures. Insurance companies provide coverage to patients through benefit plans that are private (purchased by the individual), provided by an employer or provided through government programs.

Note: Many people obtain coverage through another person’s insurance coverage (spouses, children, etc.)

Depending on the type of plan, the coverage may be for full or partial, and the patient may be responsible to pay deductibles, and/or any amounts not covered by their insurance. Some plans contain multiple people with the same coverage. The benefit plan has the same insurance company, group number (the benefit plan ID) and coverage, but each person on the plan has a different subscriber number.

In the cases of employer-provided plans, many companies provide insurance benefit plans that covers some or all of their employees’ dental procedures and expenses. Some companies have multiple benefit plans that provide varying levels of coverage linked to them. This is more common for companies in multiple states/provinces because insurance providers often vary by region.

When an employee with a company benefit plan becomes a patient, and has their employer added to their record, you can add the employer’s insurance to the patient.

Tips:

  • Before you link an employer’s insurance to a patient, confirm the plan exists in the employer record.

  • Depending on your institution's workflow, employer-provided insurance may be linked from the Employer tab. However, if an employee benefit plan has been linked to a patient, its details are available from the Insurance tab.

To specify a benefit plan:

  1. With the Patient Info window open, click the Employer or Insurance tab.
  2. Click the Link to Insurance Benefit Plan () icon to display the Select Benefit Plan window and search for the appropriate benefit plan.
    • If listed in the results, double-click the entry and close the Select Benefit Plan window.
      1. When prompted, click Yes to confirm you want to add a policy to the plan and display the Policy Information window.

      2. From the Policy Information window, complete the following fields and click OK.

        3. Field Description
        Holder

        This field indicates the policy holder (in most cases, the patient).

        Select the correct policy holder.
        Subscriber#

        Enter the subscriber/patient number for this plan.
        Start Date

        Enter the date the coverage takes effect.
        End Date

        Enter the date (if known) that the policy coverage will end.
    • If the benefit plan is not in the Select Benefit Plan window, close the window.
      1. From the Insurance tab, complete the fields as necessary and click the Add a new Record () icon.

        2. Warning: Information added under the Benefit Plan Information section affects all policy subscribers on the plan; information added under the Policy Information section affects only the individual subscriber.

        Field Description
        Insurance

        Click the ellipsis to select the insurance company that holds the benefit plan.
        Coverage...

        Click the button to open one of the following windows:

        • Benefit Plan Coverage: Displays if the coverage is unique to this benefit plan.
        • Linked Coverage Template: Displays if the benefit plan uses a generic coverage template that is shared between multiple benefit plans.
        Group / Division

        Enter the policy’s group number and division number.
        Employer

        Select the employer that provides the benefit plan.
        Description

        Enter a short description of the policy coverage.
        Coverage

        Enter the coverage type.
        Contract Click the ellipsis to select a contract policy code if the plan is a contract plan.
        Fee Sch

        Click the ellipsis to select the fee schedule code used for this benefit plan.

        Note: This defaults to the code assigned in the Insurance Company window > Default Fee field. It can be changed after the insurance policy is added.
        Override...

        Note: This button is only enabled if the Contract field is set to a contract policy code.

        Click the button to display the Contract Fee Schedule Overrides window and select an override to the contract's fee schedule for specified providers.

        Note: Previously, this button was labeled Specialists....
        Plan Type

        Select the plan type.

        Note: This defaults to the code assigned in the Insurance Company window for the company selected. It can be changed after the policy is added.
        Forms To

        Select where claims must be submitted:

        • Insurance: to the patient’s insurance company.
        • Patient: to the patient.
        • Employer: to the employer.
        • Office: to the institution’s office.

        Note: Use Office if your institution has its own insurance company. axiUm can also handle grants and discounts that are not insurance plans at the institution’s office.
        Can have multiple subscribers

        Select the checkbox if others can subscribe to the benefit plan.

        Note: If the plan is provided by an employer, it must be accessible to other employees from the same company.
        Charge Deduct and Pt Charge

        Select the checkbox if patients can be charged deductibles and amounts not covered by insurance.

        Tip: Patients on contract plans will likely have this checkbox deselected.

        Co-pay

        Enter an applicable fee charged once per date that is part of the total fees owed and must be paid by the patient.

        Note: Many institutions use this field to discourage policy holders from over-using their plans.
        Visit Fee

        Enter an applicable visit fee charged once per date, that is part of the total fees owed and must be paid by the patient.

        Note: This field is visible if the insurance company charges patient visit fees. This is enabled from Maintenance > Insurance tab > Insurance Companies > Advanced button > Charge Patient Visit Fees checkbox.

        Override...

        Click the button to display the Visit Fee Overrides window and set different office visit fee amounts for different provider types.

        Note: This button only displays if the Visit Fee field displays.
        [Patient] Deduct Enter the amount paid by the patient before their plan coverage begins and how often it is paid.
        [Patient] Limit

        Enter a limit option and the patient’s yearly coverage limit for this policy, if applicable.

        Note: If No is selected, the text field is disabled.

        Yr End ___ Month / __ Day

        Enter the month and day that represent year end.

        Example: 6, 30 represents June 30

        [Family] Deduct

        Enter the deductible amount paid by the family.

        Note: If entered, the Limit field under Policy Information is enabled and auto-filled.

        [Family] Limit

        Enter a limit option and the family’s yearly coverage limit for this policy, if applicable.

        Note: If No is selected, the text field is disabled.
        Change Date

        Enter the date the policy information was last changed.
        Assignment

        Select the checkbox if the institution accepts assignment from the company.

        Note: This field defaults based on the insurance company setup. It can be changed after the policy is added.

        Write Off

        Select the checkbox if patients may have their charges written off when the insurance company's procedure coverage is higher than the amount charged by the clinic.

        Note: The insurance company is billed their amount, but the patient portion is written off automatically.

        Example: If the regular fee amount is $40, and insurance will cover 60% of $100, the insurance company is billed $60 and the patient billed $0. In most cases, an agreement between the clinic and insurance company is required to use this option.

        Sig Req’d

        Select the checkbox if the insurance company requires policyholder and patient's signatures on claim forms.

        Notes:

        • If deselected, the claim form prints Signature on File in the signature areas of the form.
        • The checkbox default is based on Insurance Company Advanced Options window > Signature Required checkbox. You can change this field after the policy is added.
        Start Date / End Date Select the date on which the benefit plan becomes effective for all subscribers, and ends, if applicable.

        Field Description
        Holder

        Select the policy holder’s name.
        Subscriber#

        Enter the policy holder’s subscriber ID.

        Note: The number may be partially masked with asterisks if the institution is configured to preserve confidentiality.
        Start Date / End Date

        Select the date on which the individual subscriber’s policy becomes effective, and ends, if applicable.
        Deduct

        Enter the family deductible balance still owed for this policy.

        Note: This field is enabled if the Family section > Deduct field is populated.
        Limit

        Enter the balance of the family's coverage limit for this policy.