Coverage Templates

Key Info  
Purpose:

Configure the list of coverage templates.
Related Module(s):

Insurance, Patients

Accessed From:

Maintenance > Insurance > Coverage Templates
Window(s):

Coverage Template List

Edit Coverage Template

Copy Coverage Template

Template Age-specific Coverage

Deductible Exemptions for Coverage Template

Coverage Limited Procedures

Select Tooth Sites

Dependencies:

Procedure Codes List

Coverage Template List Window

A coverage template defines the policy coverage for dental treatment. Each coverage template is a list of treatments that an insurance policy will or will not pay for. It is made up of ranges of procedure codes that are covered at certain percentages.

Coverage templates are used in the Patient Card when entering insurance information.

The Coverage Template List window allows you to create and manage a list of templates for use at your institution. These templates are only used for the insurance policies that the dental faculty accepts payment for.

Note: A coverage template can be copied into or linked to a patient's insurance policy. For copied templates, you can make changes to the coverage without modifying the original template or affecting other patients with the same plan. For linked templates, when a change is made to the original template, it is reflected immediately in the policy records of patients with the same template.

Field Description

Regular Templates / Rider Templates

Radio buttons that identify the type of coverage template:

  • Regular Templates: These are base plans that typically include core insurance coverage. They are designed to cover standard, everyday dental needs. If selected, only regular templates display in the list.

  • Rider Templates: These are typically an endorsement or amendment to a base plan that extends coverage beyond the standard terms, acting as an add-on or extra. If selected, only rider templates display in the list.
Code

A text field that indicates the unique numeric ID code that identifies the template.
Description

A text field that describes the coverage in the template.

Example: 100/80/50
Task Procedure
Add Coverage Templates
  1. Click the Clear Data () icon.
  2. Complete the fields as necessary and click the Add a new Record () icon.
Edit Coverage Templates
  1. Select a listed entry.
  2. Make any necessary changes and click the Modify Record () icon.
Move Coverage Templates
  1. Select a listed entry.
  2. Click the Up / Down buttons as necessary to change the order.

    3. Tip: If you need to move a template quickly up or down the list, enter the code that you want to move the template near to in the Move field and click Go.

    Example: If you want to move a Code 10000 template up the list between Code 10 and Code 11, enter 10.
Move Coverage Templates To
  1. Select a listed entry.
  2. Click the Up / Down buttons as necessary to change the order.
Delete Coverage Templates
  1. Select a listed entry and click the Delete Record () icon.
  2. When prompted, click Yes to confirm the deletion.
Preview/Print Report
  1. (Optional) To preview the Coverage Templates report, click the Preview Report () icon.
  2. To print the Coverage Templates report, click the Print Report () icon.
Specify Coverage Items
  1. Select a listed entry and click the Coverage Items () icon to display the Edit Coverage Template window.

  2. Make any necessary changes and close the window.
Copy Coverage Template
  1. Select a listed entry and click the Copy Coverage Template () icon to display the Copy Coverage Template window.
  2. Complete the fields as necessary and click OK.

Edit Coverage Template Window

(Maintenance > Insurance > Coverage Template List)

The Edit Coverage Template window allows you to review and update information about a regular or rider coverage template. It displays when you open the Coverage Template List window, select a listed template, and click the Coverage Items () icon.

Field Description
Coverage / Description

Read-only fields that identify the selected coverage template.
Item # A text field that indicates the item number of the procedure range. It is used to sort the list.

Name

A text field that indicates the name of the procedure range.
Category

A text field that indicates the category of the procedure range.

Examples: Basic, Major, Minor, and Ortho.
From / To

Text fields that indicate that the first and last ADA procedure codes for this range of procedure codes.

The ellipses are used to display the Procedure Codes List window and select a procedure code.
Age-specific Coverage

A checkbox that, when selected, indicates that coverage for the procedure range applies to a specific age range.

Note: If selected, the Age-specific Coverage Details () icon is enabled.
Percentage

A text field that indicates the coverage percentage for the procedure range.

Note: Do not use the % sign here. Enter the percentage as a whole number.
Times#

A text field that indicates the number of times this procedure in the range will be covered.

For treatments that are site and surface based, this field indicates the number of times each procedure in the range will be covered for each particular site and surface.

Note: This field is used if the procedure has a frequency limit.
Frequency

A text field that indicates the frequency that the procedure range will be covered.

A drop-down list that indicates the frequency period that the procedure range will be covered:

  • N/A

  • Month(s)

  • Year(s)

  • Policy Year(s)

  • Life time

Example: 1 per lifetime.

Note: These fields are used if the procedure has a frequency limit. A period set as 1 per year will allow the procedure to be performed once in a 365 day period, whereas a period set as 1 per policy year will allow the procedure to be performed once per fiscal year. i.e., the policy year end is on 6/30 so they could have an exam posted on 6/20 that is covered and another exam on 7/20 that will also be covered.

Patient Charge

A text field that indicates the dollar ($) amount that will be charged to the patient whenever a procedure within the range is entered.

This is the per procedure co-pay amount.
Only covered for certain sites

A checkbox that, when selected, indicates that the procedure is only covered for specific sites and displays a Sites... button.
Sites... A button that displays the Select Tooth Sites window and allows you to manage the tooth sites applicable to the selected procedure range.
Has Category Limit/Deduct A checkbox that, when selected, indicates that this coverage range has a category limit and / or deductible.
Cat Deduct

A text field that indicates the dollar ($) amount of the category’s deductible.

Note: This field is only enabled if the Has Category Limit/Deduct checkbox is selected.
Cat Limit _ is a _

A checkbox that, when selected, indicates that there is a category limit.

A text field that indicates the dollar ($) amount of the limit.

A drop-down list the indicates the type of limit:

  • Insurance Limit

  • Patient Maximum

  • Patient Maximum (plus Deductible)

Note: These fields are only enabled if the Has Category Limit/Deduct checkbox is selected.
Cat Period

A text field and drop-down list that indicate the time period for which the category deductible and limit applies:

  • N/A 

  • Month(s)

  • Year(s)

  • Life time

Note: These fields are only enabled if the Has Category Limit/Deduct checkbox is selected.
Affects Patient/Family Limit/Deduct

A checkbox that, when selected, indicates that the patient or family deductible and limit balance as well as the category deductible and limit balance are affected when a procedure in this category is performed.

Note: This field is only enabled if the Has Category Limit/Deduct checkbox is selected.
Has Item Limit/Deduct A checkbox that, when selected, indicates that the coverage range has an item limit and / or deductible.
Item Deduct

A text field that indicates the dollar ($) amount of the item’s deductible.

Note: This field is only enabled if the Has Item Limit/Deduct checkbox is selected.
Item Limit

A checkbox that, when selected, indicates that there is an item limit.

A text field that indicates the dollar ($) amount of the limit.

Note: This field is only enabled if the Has Item Limit/Deduct checkbox is selected.
Item Period

A text field and drop-down list that indicate the time period for which the item deductible and limit applies:

  • N/A 

  • Month(s)

  • Year(s)

  • Life time

Note: This field is only enabled if the Has Item Limit/Deduct checkbox is selected.
Affects Patient/Family Limit/Deduct

A checkbox that, when selected, indicates that the patient or family deductible and limit balance as well as the item deductible and limit balance are affected when a procedure in this category is performed.

Note: This field is only enabled if the Has Item Limit/Deduct checkbox is selected.
Task Procedure
Add Procedure Ranges
  1. Click the Clear Data () icon.
  2. Complete the fields as necessary and click the Add a new Record () icon.
Edit Procedure Ranges
  1. Select a listed entry.
  2. Make any necessary changes and click the Modify Record () icon.
Delete Procedure Ranges
  1. Select a listed entry and click the Delete Record () icon.
  2. When prompted, click Yes to confirm the deletion.
Specify Age-specific Coverage Details
  1. Select a listed entry and click the Age-specific Coverage Details () icon to display the Template Age-specific Coverage window.
  2. Manage the coverage details as necessary and close the window.
Specify Deductible Exemptions
  1. Click the Deductible Exemptions () icon to display Deductible Exemptions for Coverage Template window.
  2. Manage the procedures as necessary and close the window.
Specify Coverage limited Procedures
  1. Click the Coverage Limited Procedures () icon to display the Coverage Limited Procedures window.
  2. Manage the procedures as necessary and close the window.

Copy Coverage Template Window

(Maintenance > Insurance > Coverage Template List)

The Copy Coverage Template window allows you to make a copy of the currently selected coverage template.

The new template will be created with the Code, Order, and Description that you enter here. Once the copy has been made, you can make changes to the coverage without modifying the original template or affecting other patients with the same plan.

The Copy Coverage Template window displays when you open the Coverage Template List window, select a listed template, and click the Copy Coverage Template () icon.

Field Description
Copy From

A read-only field that identifies the selected coverage template.
Code A text field that uniquely identifies the new coverage template.
Description

A text field that identifies the new coverage template.
Task Procedure
Copy Coverage Templates
  1. Complete the fields as necessary and click OK.

Template Age-specific Coverage Window

(Maintenance > Insurance > Coverage Template List > Edit Coverage Template)

The Template Age-specific Coverage window allows you to manage sub-templates for age-related procedure limitations in a coverage template.

It displays when you open the Edit Coverage Template window, select a listed procedure, and click the Age-specific Coverage Details () icon.

Field Description
Item # / Name / Category

Read-only fields that indicate the selected coverage item.
Age / To

Text fields that indicate the ages to and from that the procedure range is covered.

Note: The age limit cannot extend past the main policy's age limits.

Example: A main policy covers children up to age 18. A rider can be set up to provide additional coverage up until a younger age (e.g. 17), but cannot extend coverage past age 18. For a child rider coverage to be in effect, you must indicate the age limit. If you enter 0, the child rider coverage will not be in effect. If there is an adult rider coverage specified, axiUm will use that instead. If an adult rider coverage does not exist, axiUm uses the main policy coverage.
Percentage

A text field that indicates the coverage percentage for the procedure range.

Note: Do not use the % sign here. Enter the percentage as a whole number.
Times#

A text field that indicates the number of times this procedure range will be covered.

Note: This field is used if the procedure has a frequency limit.
Frequency

A text field that indicates the frequency that the procedure range will be covered.

A drop-down list that indicates the frequency period that the procedure will be covered:

  • N/A

  • Month(s)

  • Year(s)

  • Policy Year(s)

  • Life time

Example: 1 per lifetime.

Note: These fields are used if the procedure has a frequency limit. A period set as 1 per year will allow the procedure to be performed once in a 365 day period, whereas a period set as 1 per policy year will allow the procedure to be performed once per fiscal year. i.e., the policy year end is on 6/30 so they could have an exam posted on 6/20 that is covered and another exam on 7/20 that will also be covered.

Patient Charge

A text field that indicates the dollar ($) amount that will be charged to the patient whenever a procedure within the range is entered.

This is the per procedure co-pay amount.
Only covered for certain sites

A checkbox that, when selected, indicates that the procedure is only covered for specific sites and displays a Sites... button.
Sites... A button that displays the Select Tooth Sites window and allows you to manage the tooth sites applicable to the selected procedure range.
Task Procedure
Add Procedures
  1. Click the Clear Data () icon.
  2. Complete the fields as necessary and click the Add a new Record () icon.
Edit Procedures
  1. Select a listed entry.
  2. Make any necessary changes and click the Modify Record () icon.
Delete Procedures
  1. Select a listed entry and click the Delete Record () icon.
  2. When prompted, click Yes to confirm the deletion.

Deductible Exemptions for Coverage Template Window

(Maintenance > Insurance > Coverage Template List > Edit Coverage Template)

The Deductible Exemptions for Coverage Template window allows you to manage which procedures on the coverage template are exempt from deductibles.

Example: Some plans may provide deductible exemptions for preventive and diagnostic procedures for children only. This lets you specify exemptions on a child template with no affect on the adult template using the same benefit plan.

The Deductible Exemptions for Coverage Template window displays when you open the Edit Coverage Template window and click the Deductible Exemptions () icon.

Field

 Description
Coverage

A read-only field that indicates the selected coverage template.
Criteria

A text field that is used to enter your search criteria.

Tip: You can enter the first few characters of the word, or enter an underscore (_) to return all results.

Type of Code

A drop-down list that indicates which type of code to search on:

  • ADA: American Dental Association codes.
  • CPT: Current Procedural Terminology codes.
Search On

A drop-down list that indicates the field to search on:

  • Code
  • Description
Task Procedure
Search for Exemptions
  1. Use the Criteria field and the Type of Code and Search On drop-down lists to set the search parameters.
  2. Click Search and review the results.

    3. Note: If your search has more than 100 results, a prompt displays. Click Yes to continue your search or click No to stop and change your criteria to narrow the results list.

Add Deductible Exemptions
  1. Under Procedures (searched for), select a listed procedure and click the () button to move to the Selected Procedures list box.
  2. Repeat as necessary for each procedure you want to add.
Remove Deductible Exemptions
  1. Under Selected Procedures, select a listed procedure and click the () button to move to the Procedures (searched for) list box.
  2. Repeat as necessary for each procedure you want to remove.

Coverage Limited Procedures Window

(Maintenance > Insurance > Coverage Template List > Edit Coverage Template)

The Coverage Limited Procedures window allows you to manage procedures that have specific coverage limits.

It displays when you open the Edit Coverage Template window and click the Coverage Limited Procedures () icon.

Field

 Description
Coverage

A read-only field that indicates the selected coverage template.
Description

A read-only field that describes the selected coverage template.
Item # A text field that indicates the numeric item number used to sort the list.
Name A text field that indicates the name for the individual line or category being defined.
Times#

A text field that indicates the number of times this procedure will be covered.

Note: This field is used if the procedure range has a frequency limit.
Frequency

A text field that indicates the frequency that the procedure will be covered.

A drop-down list that indicates the frequency period that the procedure will be covered:

  • N/A

  • Month(s)

  • Year(s)

  • Policy Year(s)

  • Life time

Example: 1 per lifetime.

Note: These fields are used if the procedure range has a frequency limit. A period set as 1 per year will allow the procedure to be performed once in a 365 day period, whereas a period set as 1 per policy year will allow the procedure to be performed once per fiscal year. i.e., the policy year end is on 6/30 so they could have an exam posted on 6/20 that is covered and another exam on 7/20 that will also be covered.
Procedure List The ellipsis is used to display the Selecting Procedures (for Coverage Limited Procedures) window and select one or several procedures.
Task Procedure
View Coverage Limited Procedures
  1. Select a listed entry and review the information as necessary.
Add Coverage Limited Procedures
  1. Click the Clear Data () icon.
  2. Complete the fields as necessary and click the Add a new Record () icon.

Edit Coverage Limited Procedures

  1. Select a listed entry.
  2. Make any necessary changes and click the Modify Record () icon.
Delete Coverage Limited Procedures
  1. Select a listed entry and click the Delete Record () icon.
  2. When prompted, click Yes to confirm the deletion.

Select Tooth Sites Window

(Maintenance > Insurance > Coverage Template List > Edit Coverage Template)

The Select Tooth Sites window allows you to select the tooth sites applicable to the selected benefit plan coverage.

It displays when you open the Edit Coverage Template window and click the Sites.... button.

Task Procedure
Specify Tooth Sites
  1. Select and deselect checkboxes as necessary.

    2. Tip: Click Select All to select all the tooth sites. Click Deselect All to deselect all the currently selected tooth sites.

  2. Click OK.