Adding Insurance Details To A Patient

This tutorial will guide you through the process of adding insurance to a patient's account and creating a new insurance plan in Archy.

Search for your patient using the Search option located in the left-hand toolbar.

Select your patient and then choose Insurance.

If the patient had previously filled out their insurance details, you'd see their information loaded on the screen. This includes the subscriber information, subscriber ID, the carrier, and the employer.

Add a new insurance plan by clicking the blue + next to Insurance Plans.

Start with the subscriber page. Here, your first task is to select the insurance Carrier from the dropdown menu.

You can search for the insurance carrier in three ways: by payer ID, by carrier name (e.g., Delta Dental), or by state. For instance, if searching for Delta Dental of California, type "California" to see all relevant plans or carriers for that state.

Remember, payer IDs can vary across clearinghouses. If you don't find the payer ID provided by the insurance carrier, searching by name or state will still yield the correct payer ID for our clearinghouse, DentalXChange, to send electronic claims.

Choose the Subscriber Type. Determine if the patient is the subscriber or a dependent.

Enter the subscriber's ID or Social Security number.

- If the patient is the primary subscriber:

- If the patient is a dependent:

Input the subscriber details such as first name, last name, date of birth, and the patient's relationship to the subscriber. If this subscriber exists in Archy, they will be linked. If they don't exist, Arhcy will create them as a non-patient for insurance purposes.

Enter the eligibility Start Date of the insurance plan. This date should have been obtained when verifying the insurance either by calling the insurance company or using their web portal.

Enter the Eligibility End Date only when the patient no longer has active coverage for that plan.

Add Subscriber Notes where you can include information about the insurance that specifically pertains to the subscriber or the patient. For example, note if the grandparent has guardianship and is the subscriber.

Set the Release of Patient Information and Assignment of Benefits. Remember, the default setting for releasing patient information is 'yes', which allows the practice to send the patient's personal data on claims to insurance carriers.

Determine who receives the insurance payment in the Assignment of Benefits section. The default is set to the practice, but if you're a fee-for-service provider where the patient pays in full and receives reimbursement from the insurance, select Patient.

After entering all details, click Save.

On the next screen, click Verify to manually confirm that you have contacted the insurance carrier and verified the breakdown and eligibility.

Then click Next.

Move to the Carrier and Plan page, where carrier details such as the name, payer ID, phone numbers, fax numbers, website, and claims mailing address are displayed.

In the Plan Section, use the drop-down menu to search for plans associated with the carrier. You can search by Group Number, Nickname, Group Name, or Employer. This will attach the plan and all its details to the patient.

In this tutorial, we'll learn how to search for a non-existent plan and create a new one in the system. This process is essential when you encounter a situation where a patient's group number doesn't match any existing plans.

Search for the plan using the group number "1236547". If no groups are associated with this number in Delta Dental of California, you'll receive a notification informing you of this.

Click Create a new plan to initiate the creation of a new insurance plan.

The "Add Insurance Plan" modal will appear on the right-hand side of your screen.

Begin entering the details of the new plan. Start by adding or changing the insurance carrier. This option allows you to correct any incorrect information provided by the patient.

Enter the group number for the new plan.

Assign a nickname to the plan. This nickname serves as an internal note to help you quickly identify differences between similar plans, such as those offered by the same employer but with varying benefits.

Enter the group name.

Add the employer's name. The group name and employer might be the same or different, depending on the company and insurance carrier.

Select the plan type. Options may include PPO, HMO, Medicaid, or Medicare.

Choose the appropriate fee schedule for the plan. When you're out of network, you'll typically attach your UCR fee or your office fee schedule in Archy. Additionally, Archy allows you to create Blue Book fee schedules for any insurance with which you may be out of network. If you're in network with the insurance, attach the corresponding in-network fee schedule for that carrier.

Determine when the benefits renew. Select the month in which Archy needs to roll over or reset the benefits for that plan.

Address the waiting period. This option is for plans that include a waiting period covering the entire plan, typically six months or twelve months. This setting is not commonly used.

Set the dependent's maximum age. This is the age at which dependents are no longer covered under the insurance.

Choose the coordination of benefits for patients with dual coverage. Options include standard (one plan pays as primary, the other as secondary), none (both plans pay independently without coordinating), or other (used for plans with a non-duplication clause on the secondary plan).

Determine the eligibility coverage level. Decide if it is an individual plan or a family plan.

Confirm out-of-network benefits. Check if patients still have coverage when out of network.

Determine if there is a missing tooth clause.

Select whether crowns and bridges are paid based on the seat date or the prep date.

After entering the basics of the insurance plan, proceed to the carrier contact information at the bottom.

Indicate if you've contacted the carrier. If yes, provide details of the interaction, including the name of the person you spoke with and any confirmation number provided during the call. This information is crucial for reference in case of a denial stating that the patient isn't eligible.

Click Save to confirm the plan details you've entered.

Click Next to proceed to the next page, which covers deductibles, maximums, and the coverage table.

On this page, observe that only certain options are available for editing. This restriction is in place because changes to the total benefit or the coverage table impact all patients enrolled in this plan.

Notice the alert at the top of the page indicating how many patients are attached to the plan and will be affected by any modifications.

To edit the plan details, click Edit Plan Details in the upper right-hand corner of the page. After clicking, all fields on the page become editable.

Enter the maximums for the plan. Decide whether it's an individual lifetime, individual annual, or a family annual maximum. Remember, only one of these options can be selected per plan.

Next, enter the ortho maximum, which is fifteen hundred dollars, with the full amount still available. Also, specify the age limit for ortho coverage, which in this case is eighteen years.

Finally, input deductibles. Choose between individual lifetime, individual annual, or family annual. Note that while you can have both an individual and a family annual deductible, combining a lifetime deductible with either an individual or family annual is not permissible.

Scroll down to the coverage table on the page.

Update the coverage percentages for each plan by navigating through the coverage column.

Add any specific codes or groups of codes that do not fall within their traditional categories to ensure the accuracy of the plan. For instance, if periodontics is generally covered at 80%, but perio maintenance is covered at 100%, add this exception.

Click the plus coverage button at the bottom of the first column, select the perio category, and search for perio maintenance by code number, part of its name, or its short name. This ensures that all periodontal treatments are covered at 80%, except for this specific code, at 100%.

Move to the waiting periods section and update as necessary. For example, set six months for basic treatments and twelve months for major treatments. For demonstration, assume a six-month waiting period for crowns.

Update the co-pay column as required. This is applicable for plans where certain treatments like fillings or oral surgeries have a fixed co-pay, such as $10 for fillings or $20 for oral surgery procedures.

Review the next column for deductibles. Check if the deductible applies to each category. By default, it is turned off for diagnostic X-rays and preventative categories and turned on for all other categories.

Move to the last column to address if pre-authorization is required. Note down internally if pre-authorization is needed for specific categories such as prosthodontics, removable, and maxillofacial prosthetics.

Once the coverage table is complete, click Save.

At the top of the page, click the last category to fill out, which covers frequencies and limitations.

On the frequencies and limitations page, heed the warning about how updates will affect patients on this insurance plan.

Default the first page to the default limitations as discussed in module one, focusing on the limitations and frequencies most important to your practice.

Click Edit Plan Details in the upper right corner to begin editing these frequencies.

For simple frequencies like exams, which occur twice per benefit year, select twice from the dropdown and enter any age limitations if applicable.

For more specific frequencies, use the slider box to access more options. For instance, FMXs and Panos are typically once per visit every sixty months from the service date. Add any minimum or maximum age restrictions here.

Scroll down to the section where you enter the service history provided by the insurance. Select the relevant service and input the dates provided.

Add any specific plan notes that apply to every patient under this plan. For example, note if occlusal guards are not covered for bruxism except within six months of osseous surgery.

Save your entries. After saving, navigate to the top of the page to access the "all limitations" page.

On the "all limitations" page, add any additional frequency limitations that aren't included in the default settings. To modify this page, click on edit plan details in the upper-right corner.

At the bottom of the page, use the plus limitation option to specify any unique frequency limitations or age restrictions for certain codes.

Review and add any applicable downgrades, such as downgrading posterior composites to amalgams. Archy automatically inserts typical downgrades into new plans. If the automatic downgrades do not apply, remove them by clicking the trash can icon next to the downgrade on the "all limitations" page. This ensures they do not appear in your treatment planner.

Use the plus limitations button to create any additional downgrades as needed.

Once you've addressed all other limitations or downgrades, click save to finalize the insurance setup for your patient.

Click on the insurance tab to view the insurance plan you've just created.

Review the breakdown of the insurance plan. This confirms it as the primary insurance for your patient.

To add a secondary or tertiary plan to your patient's account, click the blue plus at the top of the page and repeat the steps for adding these additional insurances.

You've now successfully added insurance to your patient's account and created a new plan in Archy.