Insurance carriers, plans and benefits

Set up the US carriers and plans the practice bills, and keep each plan's benefit design so estimates and claims cite the right figures.

These pages are for practices in the United States. A practice in another country does not see them, and the API refuses insurance requests from one.

Insurance lives in three settings pages, all under Insurance in the settings hub and visible to roles with the insurance permission at a US practice.

Carriers

Settings → Insurance carriers lists the payers. Each carrier carries its payer id (for electronic claims), an NEA payer id when it accepts electronic attachments, its address and phone, and two switches: whether it accepts electronic attachments and whether it answers eligibility checks. Archive a carrier the practice no longer bills; its plans stay readable.

The payer id is what a claim names the carrier by, and it is also what a secondary or tertiary claim tells the next payer about the payers before it: a coordinated claim carries the prior payer's id exactly as it stood on the claim Smileline sent that payer. Keep it as the clearinghouse lists it.

Plans

Settings → Insurance plans holds the employer and group plans under each carrier. A plan names its carrier, plan type (PPO, HMO, indemnity, discount or Medicaid), its Network, employer, group name and number, and its renewal month for a plan whose benefit year does not follow the calendar.

Network says whether the practice is in the plan's network (In network) or not (Out of network). An in-network PPO, Medicaid or capitation plan is contracted: its allowed amount caps what the patient is asked, and the difference is written off. Out of network, nothing is written off and the plan's out-of-network benefits apply. A legal entity with its own terms for the plan — its own fee schedule, network or both, set through the API — uses those for the treatments it performs.

Point Allowed amounts at a fee schedule to record the carrier's allowed fees; estimates then use the lower of the practice fee and that allowed amount. A capitation plan is priced from its copays instead.

An in-network PPO or Medicaid plan without a fee schedule is marked No fee schedule in the list. Its patients are not refused an estimate: they are estimated on the full fee, marked Estimate on the full fee, and their share may be lower once the insurer answers. Point the plan at its fee schedule to estimate them properly.

Benefits

Settings → Insurance benefits keeps each plan's benefit design as effective-dated revisions.

Choose the plan, then click New revision.

Enter the CDT edition the design is written against, the dates it is in force, the coverage kind (percentage or copay), and the deductibles and maximums in dollars. Blank means the plan has none.

Add one row per CDT range: the codes it covers, the category, the percentage covered, which deductible applies and the network.

Add exceptions for single codes: excluded, downgraded to another code's rate, an age limit, a frequency limit, a waiting period or a coverage override. Add copays per code or per category for a copay plan.

If this revision corrects a live one, choose it under Retire a live revision this one replaces. Save.

A revision is written once. Nothing on it can be edited afterwards, because every estimate stamps the revision it was made under. A correction is a new revision that retires the mistaken one; retired revisions stay listed.

Two live revisions of one plan can never cover the same day, and two ranges of one revision can never overlap within a network; the page refuses both with a clear message.

Claims billing identity

At the top of Settings → Insurance benefits, click Edit under Claims billing identity and enter the practice's type-2 NPI, its tax id (EIN) and its taxonomy code (122300000X for a general dental practice). They belong to the practice's legal entity, so the same fields appear under Legal entities in Practice details, with its legal name and registered address. Every claim's billing provider loop carries them, with the entity's registered address; when the site the work was done at has a different address, the claim names the site as the service facility. Sending refuses until the NPI and tax id are on file. The card also says whether this cell has a clearinghouse connection.

Each treating clinician's own registration — first and last name, specialty and type-1 NPI — is set under Legal name on their row in Practitioners.

Clearinghouse connection

Claims travel through Stedi. Support sets the cell's Stedi API key, submitter id and usage indicator, and configures a Stedi webhook for processed transactions pointing at /webhooks/stedi with the cell's shared secret as the Authorization header. While any of these is missing, the billing identity card says so, Send on a claim refuses, and the desk records outcomes by hand.