Insurance cover and estimates

Record who covers a patient, in what order, what benefit has been used this year, and estimate the insurance portion of planned treatment.

This section is for practices in the United States. It does not appear on the record of a practice in another country.

The Insurance section of the Account tab on the clinical record lists every coverage in claim order, with its plan, carrier, relationship and member number, cover dates and the benefit used this year. The row's icons — Check eligibility, Benefits used, End — carry the actions; hover one for its name. Beside Insurance, Eligibility history lists every check with the payer's answer. Claims sit under the same section.

Add cover

Click the + icon beside Insurance. Choose the subscriber:

This patient (new subscription) — pick the plan and enter the member number. The patient is covered under their own subscription.
Someone else's existing subscription — enter the member number and click Find, then pick the subscription. Use this for a dependant covered on a parent's or spouse's plan.

Set the relationship to the subscriber, the claim order (1 for primary) and the first covered day. A claim order holds one cover on any day: two covers in the same order cannot overlap, and a cover's last day is still covered. When a patient changes plans, or who is primary changes, end the old cover and add the new one from the next day.

Benefits used

Click the Benefits used icon on an open coverage to record what the carrier reports as already used this benefit year: the deductible met and the maximum used, per category. Estimates subtract these figures.

End cover

Click the End icon and enter the last covered day. A cover is ended once: its last day cannot be changed afterwards, and neither can its plan, subscriber, relationship, claim order or first day. The coverage stays on the record because estimates and claims cite it.

Eligibility history

Click the Eligibility history icon beside Insurance. The dialog names the patient and their date of birth, then lists every eligibility check on the patient, newest first: when it was requested and how (clearinghouse, payer portal or manual), the plan it checked, the answer and when it came.

The answer is a coloured pill:

Pill	Meaning
Eligible	The payer confirmed active cover.
Not eligible	The payer said the patient is not covered.
Pending	The check was sent and the payer has not answered yet.
Failed	The payer refused the check or the answer could not be read.
Parked	The check could not be delivered and waits for review.

Under the pill is what the payer said, when it said more: the plan status (such as "Active Coverage") or the reason a check failed (such as an invalid member ID). If the checks cannot be read, the dialog says so with Retry — it never shows an empty list in their place.

Estimate planned treatment

Click the Estimate planned treatment icon beside Insurance. Smileline reads every cover open on the day, in claim order, with each plan's benefit design in force then — the date at the patient's location, so an estimate made late on 31 December in New York still counts against that year's benefits.

Each planned procedure gets a row with its totals, followed by one row per cover in claim order — Primary, then Priority 2 and so on — with that plan's own figures:

Column	Meaning
Fee	The practice fee on the procedure
Allowed	On a cover's row, that plan's allowed amount: for an in-network PPO or Medicaid plan, its fee schedule's fee for the code at the procedure's location (Prices for one site); for a capitation plan, its copay; otherwise the fee
Covered	On a cover's row, the plan's percentage covered, or the copay
Deductible	On a cover's row, the part of the allowed amount that goes to that plan's deductible
Insurance	What the cover is expected to pay; on the procedure's row, every cover together
Write-off	What the plan's contract writes off rather than asks of the patient; on the procedure's row, every plan's together
Patient	On the procedure's row, the fee less the write-off and less what every cover pays

The covers are coordinated: the lowest allowed amount among the in-network contracted plans caps the treatment, and the difference is written off rather than asked of the patient; each later cover pays at most what is left; and each plan's yearly maximum is shared out across the patient's treatments in the same benefit year, so two treatments never both count on the same remaining maximum. A cover that has answered its claim is marked Answered: its figures are what it paid and wrote off.

Couldn't check

When a figure cannot be worked out, it reads Couldn't check — never a guess — and the notes say why:

the plan's fee schedule has no fee for the code at that site;
no copay on file for the code (a capitation plan);
no benefits on file for the plan's network;
no benefit design in force on the day;
a discount plan, which is priced with a price list instead;
an earlier payer's answer is waiting for a decision on the claim;
the plan limits the code by age and the patient's date of birth is missing.

The reason shows on the cover it comes from. While one procedure has a figure that cannot be checked, the totals cannot be told either.

Estimates on the full fee

An in-network PPO or Medicaid plan with no fee schedule on file at all is estimated on the full fee rather than refused: the procedure and the cover carry an Estimate on the full fee pill, and a line under the table says the patient's share may be lower once the insurer answers. Its plan is marked No fee schedule under Insurance plans; point the plan at its fee schedule and estimate again to clear it.

The notes column explains each figure: an exclusion, a downgrade, a waiting period, an age limit, a spent frequency, a reached maximum. Each estimate is kept for the procedure and the cover, so a claim and later estimates can cite it.

An estimate is not a guarantee of payment: the payer's answer is what counts.