Benefits indicate which services are covered
under a benefit plan, at what percentage, how long a waiting period you
may have, and any rules that apply. To view benefit information:
Select Benefits/Eligibility
from the menu. The Benefit Quickview screen appears.
In the Patient Information section, select the button of
the person you would like to view benefits for.The Patient Information screen
appears displaying the benefit information.
Benefit Information
Benefit information is divided into several sections. At the top of
the benefit information are any client-specific messages followed by:
The member types,
benefit member types, and specialties the benefits apply to
The name of the
benefit program
The product agreed
upon between the benefit provider and an employer group
Below this is information on benefit levels,
waiting periods, and rules, followed by maximums and deductibles, ortho
age limits, and COB information, if the benefit program includes those.
Benefit levels
For easy reference, benefit levels, waiting periods, and rules are assigned
to several standard categories. These categories in turn contain subcategories,
and within these, individual procedures or services.
To expand a category
or subcategory, click on the
To collapse it
again, click on the
Benefits may also vary by provider network.
If so, the information is displayed for each network.
Routine Procedures
list routine procedures, dates of services provided, and whether they
are covered for the participating and non participating networks.
You can also use the Code Search feature
to find benefit information for a specific procedure code or service.
Enter the procedure code and click the Find
button to jump to benefit information for that code.
For each procedure category and/or code:
Under Rules, click a button
toview messages pertaining to
this category or code.
%
— shows the percentage the benefit provider pays for this procedure category
or code. If this is in red, there are some procedure codes in the category
that have a different percentage. If there is an asterisk after it, some
items under it are not covered.
Waiting
Period — the waiting period, if any, for this procedure category
or code.
Maximums and deductibles
The maximums and deductibles section shows dollar amounts and other
information for maximums and deductibles.
For each network:
Type
— deductible or maximum
Category
— category
to which this item belongs, such as general services or orthodontic services
Suffix
— used internally to uniquely identify the maximum/deductible
Name
— the name of the maximum or deductible; click on it to see all related
procedure codes
Individual
Amount — the limit for an individual
Individual
Amount Used — the amount used by the individual
Individual
Amount Remaining — the unused portion of the individual's amount
Family
Amount — the accumulation limit for a family (all members enrolled
under a subscriber)
Family
Amount Used — the amount used by the family
Family
Amount Remaining — the unused portion of the family's amount
Accum
Period From, To — the start and end
dates of the time period for the maximum or deductible, or lifetime if
it is calculated over a lifetime