When Insurance Estimating has been correctly configured and enabled, the Insurance Estimating Formulas will be calculated as charges are made. As the Insurance Payment is entered, the Insurance Payment window will pull the variables as they are entered within the Insurance References, Plan, Allowed Amounts, and so on. The documentation below contains a Quick Reference guide to assist as a checklist for Insurance Estimating configuration and use. As portions are calculated using the configured variables, if one of the variables has been entered incorrectly or does not accurately reflect the patient's plan, it may be necessary to troubleshoot portions to determine which variable should be adjusted.

The Insurance Estimating Use Guide contains the following sections:

You can also refer to:

Insurance Estimating Charges

When Insurance Estimating has been correctly configured, the Insurance Estimating Formula variables for each code, such as the patient portion, allowed, write-off, insurance portion, and so on, will display within the code table at the bottom of the New Charge window. The total amount for each variable of all codes within the transaction will be listed beneath the table.

The variables are listed within columns.

Fee: from the Fee Schedule and Charge
Patient Portion: the percentage of allowed amount that the insurance does not cover minus the write-off, if participating
Primary Write-off: the difference between the allowed amount and the fee, if participating
Primary Allowed: the allowed amount in the Plan
Primary Insurance %: from the Plan
Primary Insurance Portion: what the insurance will pay according to insurance estimating
Primary Deductible: The amount applied to the patient's deductible

Some variables in the New Charge window can be updated directly within the field beneath the column.

To pull the Copay from Patient view, enable the Require Copay checkbox for the code within the Fee Schedule.
To change the allowed amount for a charge, click the field to change the amount. The Patient Portion will be recalculated accordingly, though the new allowed amount will not be saved back to the insurance plan.
If the deductible is changed, the dependent variables will be recalculated.
If a code has a flat rate set in the Plan, editing the percentage amount will not change the estimated insurance portion. Flat rate coverages are listed in blue within the table at the bottom of the new charge window.

Information within References > Insurance Companies > Plan will override both the Company Info and Provider IDs tabs whenever the plan is associated to an account.

Insurance Payments

The Insurance Payment window can be used to add allowed amounts to the Allowed tab of a plan as an insurance payment is made. If an allowed amount is entered with the payment, but there is not an allowed amount for that code within the plan, the Save Allowed checkbox will be checked in the insurance payment window and the corresponding allowed amount will be saved to the plan. From then on, the same allowed amount will pull to the Insurance Payment window for that procedure whenever the patient has this plan. If the provider has Participate checked for that plan, the write-off (total fee - allowed amount) will also populate in the Insurance Payment window. To override this process, uncheck Save Allowed and no allowed amount will be added to the plan.

As with Allowed Amounts, the Insurance Payment window can also be used to add Flat Rates to the patient's plan. When an insurance payment is entered, check the Save As Flat Rate checkbox in the insurance payment window to save the allowed amount as a flat rate for the code within the plan.

When Insurance Estimating is used, the Insurance Payment window will include the Apply To Unpaid checkbox, which determines how the Apply to All button works. Apply to All will only apply up to the total estimated insurance amount unless the Apply To Unpaid checkbox has been enabled, in which it will then apply to the entire unpaid portion.

MacPractice HelpDesk

Insurance Estimating - Use

Insurance Estimating Charges

Insurance Payments