How Andre Used Insurance Breakdowns In Eaglesoft

So many people post the question:

“Who has a great Insurance Breakdown Form they want to share?”

My answer would be the Edit Employer/Coverage screen.

When on the phone or reviewing an Insurance Company website, why not transcribe the information right into the Employer/Coverage screen so that when you do a Walkout or Create a Treatment Plan the data calculates for you?  How? OK.. get ready for a long explanation.

First, do you have a “great Insurance Breakdown Form”?  If not, do you have a list of Service Codes and Categories that you would want to know how a plan covers?  OK, let’s start there. 

You want to know:

• Group Name

• Group Number (ALL digits)

• Deductible

• Maximum

• Plan rollover month

• What is the mailing address for claim submission?

• What is your for of Submission (e-claims or on a “paper” ADA form)

• Dose the plan use Fee Schedule (For In-Network Providers only)

• What is the unique Adjustment Type that you want to use to track Adjustments for this plan (not necessary for plan that use Fee Schedules and/or Coverage Books)

• Percentages covered of each Service Type

• Does the plan use the Social Security Number or a Primary/Policy Holder Member ID?

 And finally, frequencies and limitation notes.

 Well, you can enter ALL that information directly into the Employer/Coverage information with a few additions. 

 You need to expand your Service Types. To create a new Service Type

List>General Setup>Service Types>New Why?  Here is a test: In a “basic” insurance setup, what percentage would you enter as a default for Prosthodontics Removable as a Service Type?  Most people would say 50% and that is kinda “correct”.  Dentures (full and partial) are typically covered at 50%.  But of the 1,000 D5XXX codes most are repairs and adjustments, which in most plans coverage is generally at 80% when means setting your Prosthodontics Removable as a Service Type at 50% leave the majority of codes (repairs and adjustments) estimated incorrectly.  Easy fix.  Split Prosthodontics Removable into two Service Types. 

1. Prosthodontics Removable – Dentures defaulted at 50%

2. Prosthodontics Removable – Repairs & Adjustments defaulted at 80%

 Now, you repeat this division of Service Type until they match the breakdown that would have been on your perfect Insurance Breakdown Form.

 Here are my Service Types: ADJUCTIVE

• ADMINISTRATIVE

• ANESTHESIA – GENERAL

• ANESTHESIA – NITROUS

• DIAGNOSTIC

• DIAGNOSTIC – FMX

• DIAGNOSTIC - MISCELANEOUS

• ENDODONTICS – BASIC

• ENDODONTICS – MAJOR

• ENDODONTICS – MISCELANEOUS

• GUARDS – OCCLUSAL

• GUARDS – SLEEP

• IMPLANT SERVICES – BODY

• IMPLANT SERVICES – RESTORATIVE

• ORAL SURGERY – MAJOR

• ORAL SURGERY – MINOR

• ORTHODONTICS – ADULT

• ORTHODONTICS – CHILD

• PALLIATIVE TREATMENT

• PERIODONTIC – MAINTENANCE

• PERIODONTIC – SURGERY

• PERIODONTIC – OTHER

• PREVENTIVE

• PREVENTIVE - NON-COVERED

• PREVENTIVE - SEALANTS – MOLAR

• PREVENTIVE - SEALANTS – PRE

• PRODUCTS

• PROSTH - FIXED - MULTI

• PROSTH - FIXED - SINGLE

• PROSTH - FIXED - SINGLE POST

• PROSTH – MAXILLOFACIAL

• PROSTH - REMOVE - DENTURES

• PROSTH - REMOVE - REPAIR/ADJ

• RESTORATIVE – ANTERIOR

• RESTORATIVE – CUSPIDS

• RESTORATIVE - POST RESIN

 These Service Types must then be attached to the corresponding Service Codes (see pic).

So, how do you get fluoride to show covered for an 11-year-old and not for a 16-year-old (assuming most plans cover to age 14).  You create a second Service Code.  One is Service Code A1206 for Adult (ADA Code D1206) Preventive – Non-covered. The second D1206 for under 14 is the "normal" one (see pic).

DISCLAIMER:

This is a resource guide and all decisions on each dental office setup should remain the sole decision of the dentist/owner of the practice. Eaglesoft is a registered trademark of Patterson Dental Company.  All other software or products mentioned are the property of their respective owners. Although Andre Shirdan was an employee of Patterson Dental, he is not associated with Eaglesoft or Patterson Dental Company or endorsed by Patterson or any other Company Mentioned in this blog.