Manage insurance payers and policies

Insurance payers, insurance payer addresses, and insurance policies are managed at the practice level.

This includes defining coverage types, percentages, limits, and exceptions at the policy level.

Once a payer, address, and policy are created, the policy can be associated with a patient record. To learn more, see Add insurance to a patient.

To access Insurance Management, go to Practice > Insurance

Create an insurance payer

Insurance payers will contain details for various addresses and policies.

1. Enter the insurance payer's name into the Search by Payer Name field
2. Confirm that the payer doesn't already exist and select Create New Payer
3. Complete the following details
   • Payer Name
   • Dental or Medical
   • Payer Type
   • Insurance Provider #
   • EDI Format
   • Form to Print
   • Website
   • Date Ranges
4. Select Save

Add an insurance payer address to an insurance payer

Once a payer has been created, an address must be added for the payer before policies can be added.

1. Select Add New Address
   • Specify:
     • Payer Abbreviation Name
     • Website
     • Whether you want to generate a claim on each ortho payment plan charge rather than just one.
     • Add any Address Notes
2. Select + Add Contact Method to add address, phone number, or email details
3. Repeat as necessary
4. Select Save

Add an insurance policy to an insurance payer address

To add an insurance policy, the insurance payer, and at least one insurance payer address must be created. Insurance policies are created at the Insurance Payer Address' screen.

If you already have a similar policy for the same payer entered and open, you can use the Duplicate Insurance Policy button in the bottom-right corner to reduce data entry.

1. Go to Practice > Insurance > Policies and Payers
2. Open the insurance payer's page by using the Search by Payer Name field
3. Select the insurance payer's name
4. Find the Listed Addresses tab in the table at the bottom
5. Select  to the right of the address you want to add a policy to
6. Select Add New Policy
7. Complete the Policy Details
   • Group Name
   • Group Number
   • Policy Type
   • Active and Inactive Date
   • Anniversary
   • Assignment
     • If you select Payer Pays Clinic, when a procedure is billed the patient and insurance will have a responsibility split.
       • You can then create Regular Claims for the insurance responsibility, submit them to insurance, and record payments from that insurance.
     • If you select Payer Pays Patient, when a procedure is billed the patient will have 100% responsibility for the cost.
       • You can still create and print a Courtesy Claim for the patient that they can submit to insurance themselves. The claim will pull the insurance information you configure here.
8. Optional: Use the Employer search field to find or add employer details relevant to this policy
9. Select Save
   • You must save the policy before adding Benefits & Limits, and Coverages & Exceptions.

Add benefits, limits, coverages, and exceptions to a policy 

Benefits, Limits, Coverages, and Exceptions can be added when editing or creating a policy.

Exceptions can include code-specific coverage differences, age requirements, or predetermination requirements for specific categories and codes.

To edit an existing policy, search for the policy using the Policy Group Number search field, or by selecting a policy from the Insurance Payer Address screen.

1. Scroll to the Benefits, Coverages, and Exceptions section at the bottom of the policy details
2. Add an Effective Date
3. Complete the Benefits table, including co-pay and the details of any applicable limits
4. Complete the Coverages table, including maximums, limits, and occurrences
5. To record exceptions, select Exceptions to the right of the relevant procedure category
6. In the Category Exceptions window select Add Exception
7. In the Add Code Exception table specify:
   • Code
   • Coverage Type ( % or $ )
   • Coverage Max
   • Whether to waive the deductible for this code.
   • Occurrences
   • Frequency
   • Min and Max Age
   • Whether this code requires a pre-authorization.
   • Whether this code should not be submitted to insurance.
   • Whether this code should be excluded from claims.
     
8. Select OK
9. To edit existing exceptions select  to the right of the exception
10. To delete an exception select  to the right of the exception
11. Select Close
    • Once an exception has been added you will see the number of exceptions added to the right of the policy category  
12. Select Save