Viewing benefits

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 to view messages pertaining to this category or code.
% — shows the percentage the benefit provider pays for this procedure category or code. 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

Ortho Age Limit

The age limits for orthodontic treatment, if applicable. If the benefit plan does not cover orthodontics, this section does not appear.

For each network:

Name — the patient's relationship to the subscriber
Max Age — the maximum age, in years, at which a member with this relationship can receive ortho benefits
Min Age — the minimum age, in years, at which a member with this relationship can receive ortho benefits
Rule — describes how to calculate the date that the age limit is reached