Setting Up Plan Detailed Benefits

The detailed benefits pricing method allows you to set up complex insurance plan benefits for precise billing. Use the detailed benefits pricing method to set up schedules of benefits for individual attributes and combinations of attributes, set the order in which payments are calculated, and set the maximum allotments.

The Detailed Benefits feature in version 15 is not currently working as it did in version 12. Eyefinity is working to restore full functionality to this feature in a future release.
  • The Detailed Benefits pricing method is only available to practices that upgraded from OfficeMate Enterprise 2.0 or OfficeMate 9.0, 9.5, or 10.0; had at least one insurance plan that used either the Detailed Benefits or Maximum Allotments pricing methods; and have the Yes radio button selected next to the “Activate Detailed Benefits and Max Allotment Calculations” financial preference. For more information about setting up financial preferences, go to To set up financial preferences.
  • If your practice does not require a complex insurance plan setup, go to Setting Up Plan Maximum Allotments or Setting Up Plan Percentages for additional options.

This section explains how to set up detailed benefits, including how

  1. Open the Plan tab on the Insurance Billing Initial Setup window. For more information, go to To open the insurance Plan tab.
  2. Select an insurance plan from the Select Plan drop-down menu.

    OR

    Click New to add a plan. For more information, go to To add & modify insurance plans.

  3. Select Detailed Benefits from the Pricing Method drop-down menu.
  4. Click Detail Benefits.

    The Detail Benefits window opens.

  1. Open the Detail Benefits window. For more information, go to To open the Detail Benefits window.
  2. Select Accessories from the Product Type drop-down menu.
  3. Click New to add a new detailed benefit group.

    OR

    Select a detailed benefit group from the list to modify it.

    If you are creating a detailed benefit that is similar to one that you have already created, click Copy to duplicate the plan, and adjust the details as needed. For information on copying maximum allotments, go to To copy detailed benefits.
  4. Select the Base information if required by the plan benefit:
    1. Select an attribute from the Attributes drop-down menu.
    2. Select a code from the Replace Code drop-down menu if the insurance carrier requires a code other than the standard CPT/HCPCS code.
    3. Select a modifier from the Modifier drop-down menu. After you record attributes with modifiers on fee slips, they appear in box 24D in the first modifier column on the CMS 1500 form.
  5. Select the Other 1 information if required by the plan benefit as needed:
    1. Select an attribute from the Attribute drop-down menu.
    2. Select a code from the Replace Code drop-down menu if the insurance carrier requires a code other than the standard CPT/HCPCS code.
    3. Select a modifier from the Modifier drop-down menu. After you record attributes with modifiers on fee slips, they appear in box 24D in the first modifier column on the CMS 1500 form.
    If the option to combine attributes for accessories is selected on the plan Preferences tab, the Other 1 drop-down menus will not be available.
  6. Select a product group from the Product Group drop-down menu as needed.
    • If the option to combine attributes for accessories is selected on the plan Preferences tab, the Product Group drop-down menus will not be available.
    • To add detailed benefit groups, go to To add & modify detailed benefit groups.
  7. Select the All Attributes Inclusive check box if products included in the product group with multiple attributes will should have all attributes included in the schedule of benefits.
  8. Click Save.

    The detail benefit group you created or the changes you made appear in the tree on the left side of the window.

  9. Repeat steps 3–8 for each of the detailed benefits covered in the plan.
  1. Open the Detail Benefits window. For more information, go to To open the Detail Benefits window.
  2. Select Contact Lenses from the Product Type drop-down menu.
  3. Click New to add a new detailed benefit group.

    OR

    Select a detailed benefit group from the list to modify it.

    If you are creating a detailed benefit that is similar to one that you have already created, click Copy to duplicate the plan, and adjust the details as needed. For information on copying maximum allotments, go to To copy detailed benefits.
  4. Select the nature of the lens’ use from the Elective, Non-Elective, or None radio buttons.
    If you select the None radio button, OfficeMate will prompt the user to select Elective or Non-Elective when a product matching the contact lens category is invoiced on a VSP order.
  5. Select the Lens Cat./Base information if required by the plan benefit:
    1. Select an attribute from the Attributes drop-down menu.
    2. Select a code from the Replace Code drop-down menu if the insurance carrier requires a code other than the standard CPT/HCPCS code.
    3. Select a modifier from the Modifier drop-down menu. After you record attributes with modifiers on fee slips, they appear in box 24D in the first modifier column on the CMS 1500 form.
  6. Select the Lens Type information if required by the plan benefit as needed:
    1. Select an attribute from the Attribute drop-down menu.
    2. Select a code from the Replace Code drop-down menu if the insurance carrier requires a code other than the standard CPT/HCPCS code.
    3. Select a modifier from the Modifier drop-down menu. After you record attributes with modifiers on fee slips, they appear in box 24D in the first modifier column on the CMS 1500 form.
    If the option to combine attributes for contact lenses is selected on the plan Preferences tab, the Lens Type drop-down menus will not be available.
  7. Select the Other 1 information if required by the plan benefit as needed:
    1. Select an attribute from the Attribute drop-down menu.
    2. Select a code from the Replace Code drop-down menu if the insurance carrier requires a code other than the standard CPT/HCPCS code.
    3. Select a modifier from the Modifier drop-down menu. After you record attributes with modifiers on fee slips, they appear in box 24D in the first modifier column on the CMS 1500 form.
    If the option to combine attributes for contact lenses is selected on the plan Preferences tab, the Other 1 drop-down menus will not be available.
  8. Enter the Pricing Range information if required by the plan benefit as needed:
    1. Type the bottom of the price range in the Low field as a dollar amount.
    2. Type the top of the price range in the High field as a dollar amount.
    • The Pricing Range radio buttons are not active. To set the price range to retail or to cost, go to the plan Preference tab. For information about the plan Preference tab, go to To open the insurance Plan tab.
    • If the option to combine attributes for contact lenses is selected on the plan Preferences tab, the Oversize drop-down menus will not be available.
  9. Select a product group from the Product Group drop-down menu as needed.
    • If the option to combine attributes for contact lenses is selected on the plan Preferences tab, the Product Group drop-down menus will not be available.
    • To add detailed benefit groups, go to To add & modify detailed benefit groups.
  10. Select the All Attributes Inclusive check box if products included in the product group with multiple attributes will should have all attributes included in the schedule of benefits.
  11. Click Save.
  12. Repeat steps 3–11 for each of the detailed benefits covered in the plan.
  1. Open the Detail Benefits window. For more information, go to To open the Detail Benefits window.
  2. Select Frames from the Product Type drop-down menu.
  3. Click New to add a new detailed benefit group.

    OR

    Select a detailed benefit group from the list to modify it.

    • If you are creating a detailed benefit that is similar to one that you have already created, click Copy to duplicate the plan, and adjust the details as needed. For information on copying maximum allotments, go to To copy detailed benefits.
    • The Split Frame radio buttons are not active. To enable or disable splitting frame costs, go to the plan Preference tab. For information about the plan Preference tab, go to To open the insurance Plan tab.
  4. Select the Frame Cat./Base information if required by the plan benefit:
    1. Select an attribute from the Attributes drop-down menu.
    2. Select a code from the Replace Code drop-down menu if the insurance carrier requires a code other than the standard CPT/HCPCS code.
    3. Select a modifier from the Modifier drop-down menu. After you record attributes with modifiers on fee slips, they appear in box 24D in the first modifier column on the CMS 1500 form.
  5. Select the Options information if required by the plan benefit as needed:
    1. Select an attribute from the Attribute drop-down menu.
    2. Select a code from the Replace Code drop-down menu if the insurance carrier requires a code other than the standard CPT/HCPCS code.
    3. Select a modifier from the Modifier drop-down menu. After you record attributes with modifiers on fee slips, they appear in box 24D in the first modifier column on the CMS 1500 form.
    If the option to combine attributes for frames is selected on the plan Preferences tab, the Other 1 drop-down menus will not be available.
  6. Enter the Pricing Range information if required by the plan benefit as needed:
    1. Type the bottom of the price range in the Low field as a dollar amount.
    2. Type the top of the price range in the High field as a dollar amount.
    • The Pricing Range radio buttons are not active. To set the price range to retail, cost, or Frame Facts, go to the plan Preference tab. For information about the plan Preference tab, go to To open the insurance Plan tab.
    • If the option to combine attributes for frames is selected on the plan Preferences tab, the Oversize drop-down menus will not be available.
  7. Select a product group from the Product Group drop-down menu as needed.
    • If the option to combine attributes for frames is selected on the plan Preferences tab, the Product Group drop-down menus will not be available.
    • To add detailed benefit groups, go to To add & modify detailed benefit groups.
  8. Select the All Attributes Inclusive check box if products included in the product group with multiple attributes will should have all attributes included in the schedule of benefits.
  9. Click Save.
  10. Repeat steps 3–9 for each of the detailed benefits covered in the plan.
  1. Open the Detail Benefits window. For more information, go to To open the Detail Benefits window.
  2. Select Lens Treatments from the Product Type drop-down menu.
  3. Click New to add a new detailed benefit group.

    OR

    Select a detailed benefit group from the list to modify it.

    If you are creating a detailed benefit that is similar to one that you have already created, click Copy to duplicate the plan, and adjust the details as needed. For information on copying maximum allotments, go to To copy detailed benefits.
  4. Select the Base information if required by the plan benefit:
    1. Select an attribute from the Attributes drop-down menu.
    2. Select a code from the Replace Code drop-down menu if the insurance carrier requires a code other than the standard CPT/HCPCS code.
    3. Select a modifier from the Modifier drop-down menu. After you record attributes with modifiers on fee slips, they appear in box 24D in the first modifier column on the CMS 1500 form.
  5. Select the Other 1 information if required by the plan benefit as needed:
    1. Select an attribute from the Attribute drop-down menu.
    2. Select a code from the Replace Code drop-down menu if the insurance carrier requires a code other than the standard CPT/HCPCS code.
    3. Select a modifier from the Modifier drop-down menu. After you record attributes with modifiers on fee slips, they appear in box 24D in the first modifier column on the CMS 1500 form.
    If the option to combine attributes for lens treatments is selected on the plan Preferences tab, the Other 1 drop-down menus will not be available.
  6. Select a product group from the Product Group drop-down menu as needed.
    • If the option to combine attributes for lens treatments is selected on the plan Preferences tab, the Product Group drop-down menus will not be available.
    • To add detailed benefit groups, go to To add & modify detailed benefit groups.
  7. Select the All Attributes Inclusive check box if products included in the product group with multiple attributes will should have all attributes included in the schedule of benefits.
  8. Click Save.
  9. Repeat steps 3–8 for each of the detailed benefits covered in the plan.
  1. Open the Detail Benefits window. For more information, go to To open the Detail Benefits window.
  2. Select Ophthalmic Lenses from the Product Type drop-down menu.
  3. Click New to add a new detailed benefit group.

    OR

    Select a detailed benefit group from the list to modify it.

    If you are creating a detailed benefit that is similar to one that you have already created, click Copy to duplicate the plan, and adjust the details as needed. For information on copying maximum allotments, go to To copy detailed benefits.
  4. Select one of the following from the Power Ranges radio buttons.
    • Select Yes to automatically populate the claim form with the CPT/HCPCS code based on the lens’ power range.
    • Select No to populate the claim form with the CPT/HCPCS of the base lens.
  5. Select the Cat./Base information if required by the plan benefit:
    1. Select an attribute from the Attributes drop-down menu.
    2. Select a procedure code from the CPT/HCPCS Code drop-down menu.
      If you selected Yes from the Power ranges radio buttons in step 4, the CPT/HCPCS Code drop-down menu will not be available.
    3. Select a code from the Replace Code drop-down menu if the insurance carrier requires a code other than the standard CPT/HCPCS code.
    4. Select a modifier from the Modifier drop-down menu. After you record attributes with modifiers on fee slips, they appear in box 24D in the first modifier column on the CMS 1500 form.
  6. Select the Single Vision, Multifocal, or None radio button as needed.
    The Single Vision, Multifocal, and Name radio buttons are only available if the Lens Cat./Base field is blank. If you selected the Lens Cat./Base information in step 5, these radio buttons will not be available.
  7. Select the Lens Type information if required by the plan benefit as needed:
    1. Select an attribute from the Attribute drop-down menu.
    2. Select a code from the Replace Code drop-down menu if the insurance carrier requires a code other than the standard CPT/HCPCS code.
    3. Select a modifier from the Modifier drop-down menu. After you record attributes with modifiers on fee slips, they appear in box 24D in the first modifier column on the CMS 1500 form.
    If the option to combine attributes for ophthalmic lenses is selected on the plan Preferences tab, the Lens Type drop-down menus will not be available.
  8. Select the Material information if required by the plan benefit as needed:
    1. Select an attribute from the Attribute drop-down menu.
    2. Select a code from the Replace Code drop-down menu if the insurance carrier requires a code other than the standard CPT/HCPCS code.
    3. Select a modifier from the Modifier drop-down menu. After you record attributes with modifiers on fee slips, they appear in box 24D in the first modifier column on the CMS 1500 form.
    If the option to combine attributes for ophthalmic lenses is selected on the plan Preferences tab, the Material drop-down menus will not be available.
  9. Select the Color information if required by the plan benefit as needed:
    1. Select an attribute from the Attribute drop-down menu.
    2. Select a code from the Replace Code drop-down menu if the insurance carrier requires a code other than the standard CPT/HCPCS code.
    3. Select a modifier from the Modifier drop-down menu. After you record attributes with modifiers on fee slips, they appear in box 24D in the first modifier column on the CMS 1500 form.
    If the option to combine attributes for ophthalmic lenses is selected on the plan Preferences tab, the Color drop-down menus will not be available.
  10. Select the Other 1 information if required by the plan benefit as needed:
    1. Select an attribute from the Attribute drop-down menu.
    2. Select a code from the Replace Code drop-down menu if the insurance carrier requires a code other than the standard CPT/HCPCS code.
    3. Select a modifier from the Modifier drop-down menu. After you record attributes with modifiers on fee slips, they appear in box 24D in the first modifier column on the CMS 1500 form.
    If the option to combine attributes for ophthalmic lenses is selected on the plan Preferences tab, the Other 1 drop-down menus will not be available.
  11. Select the Prism information if required by the plan benefit as needed:
    1. Select an attribute from the Attribute drop-down menu.
    2. Select a code from the Replace Code drop-down menu if the insurance carrier requires a code other than the standard CPT/HCPCS code.
    3. Select a modifier from the Modifier drop-down menu. After you record attributes with modifiers on fee slips, they appear in box 24D in the first modifier column on the CMS 1500 form.
  12. Select the Add Power information if required by the plan benefit as needed:
    1. Select an attribute from the Attribute drop-down menu.
    2. Select a code from the Replace Code drop-down menu if the insurance carrier requires a code other than the standard CPT/HCPCS code.
    3. Select a modifier from the Modifier drop-down menu. After you record attributes with modifiers on fee slips, they appear in box 24D in the first modifier column on the CMS 1500 form.
  13. Select the Oversize information if required by the plan benefit as needed:
    1. Select an attribute from the Attribute drop-down menu.
    2. Select a code from the Replace Code drop-down menu if the insurance carrier requires a code other than the standard CPT/HCPCS code.
    3. Select a modifier from the Modifier drop-down menu. After you record attributes with modifiers on fee slips, they appear in box 24D in the first modifier column on the CMS 1500 form.
  14. Select a product group from the Product Group drop-down menu as needed.
    To add detailed benefit groups, go to To add & modify detailed benefit groups.
  15. Select the All Attributes Inclusive check box if products included in the product group with multiple attributes will should have all attributes included in the schedule of benefits.
  16. Click Save.
  17. Repeat steps 3–16 for each of the detailed benefits covered in the plan.
  1. Open the Detail Benefits window. For more information, go to To open the Detail Benefits window.
  2. Select Other from the Product Type drop-down menu.
  3. Click New to add a new detailed benefit group.

    OR

    Select a detailed benefit group from the list to modify it.

    If you are creating a detailed benefit that is similar to one that you have already created, click Copy to duplicate the plan, and adjust the details as needed. For information on copying maximum allotments, go to To copy detailed benefits.
  4. Select the Base information if required by the plan benefit:
    1. Select an attribute from the Attributes drop-down menu.
    2. Select a code from the Replace Code drop-down menu if the insurance carrier requires a code other than the standard CPT/HCPCS code.
    3. Select a modifier from the Modifier drop-down menu. After you record attributes with modifiers on fee slips, they appear in box 24D in the first modifier column on the CMS 1500 form.
  5. Select the Other 1 information if required by the plan benefit as needed:
    1. Select an attribute from the Attribute drop-down menu.
    2. Select a code from the Replace Code drop-down menu if the insurance carrier requires a code other than the standard CPT/HCPCS code.
    3. Select a modifier from the Modifier drop-down menu. After you record attributes with modifiers on fee slips, they appear in box 24D in the first modifier column on the CMS 1500 form.
    If the option to combine attributes for other is selected on the plan Preferences tab, the Other 1 drop-down menus will not be available.
  6. Select a product group from the Product Group drop-down menu as needed.
    • If the option to combine attributes for other is selected on the plan Preferences tab, the Product Group drop-down menus will not be available.
    • To add detailed benefit groups, go to To add & modify detailed benefit groups.
  7. Select the All Attributes Inclusive check box if products included in the product group with multiple attributes will should have all attributes included in the schedule of benefits.
  8. Click Save.
  9. Repeat steps 3–8 for each of the detailed benefits covered in the plan.
  1. Open the Detail Benefits window. For more information, go to To open the Detail Benefits window.
  2. Select Plano Sunglasses from the Product Type drop-down menu.
  3. Click New to add a new detailed benefit group.

    OR

    Select a detailed benefit group from the list to modify it.

    If you are creating a detailed benefit that is similar to one that you have already created, click Copy to duplicate the plan, and adjust the details as needed. For information on copying maximum allotments, go to To copy detailed benefits.
  4. Select the Base information if required by the plan benefit:
    1. Select an attribute from the Attributes drop-down menu.
    2. Select a code from the Replace Code drop-down menu if the insurance carrier requires a code other than the standard CPT/HCPCS code.
    3. Select a modifier from the Modifier drop-down menu. After you record attributes with modifiers on fee slips, they appear in box 24D in the first modifier column on the CMS 1500 form.
  5. Select the Other 1 information if required by the plan benefit as needed:
    1. Select an attribute from the Attribute drop-down menu.
    2. Select a code from the Replace Code drop-down menu if the insurance carrier requires a code other than the standard CPT/HCPCS code.
    3. Select a modifier from the Modifier drop-down menu. After you record attributes with modifiers on fee slips, they appear in box 24D in the first modifier column on the CMS 1500 form.
    If the option to combine attributes for ophthalmic lenses is selected on the plan Preferences tab, the Other 1 drop-down menus will not be available.
  6. Enter the Pricing Range information if required by the plan benefit as needed:
    1. Type the bottom of the price range in the Low field as a dollar amount.
    2. Type the top of the price range in the High field as a dollar amount.
    • The Pricing Range radio buttons are not active. To set the price range to retail, cost, or Frame Facts, go to the plan Preference tab. For information about the plan Preference tab, go to To open the insurance Plan tab.
    • If the option to combine attributes for plano sunglasses is selected on the plan Preferences tab, the Oversize drop-down menus will not be available.
  7. Select a product group from the Product Group drop-down menu as needed.
    • If the option to combine attributes for ophthalmic lenses is selected on the plan Preferences tab, the Product Group drop-down menus will not be available.
    • To add detailed benefit groups, go to To add & modify detailed benefit groups.
  8. Select the All Attributes Inclusive check box if products included in the product group with multiple attributes will should have all attributes included in the schedule of benefits.
  9. Click Save.
  10. Repeat steps 3–9 for each of the detailed benefits covered in the plan.
  1. Open the Detail Benefits window. For more information, go to To open the Detail Benefits window.
  2. Select Ready Readers from the Product Type drop-down menu.
  3. Click New to add a new detailed benefit group.

    OR

    Select a detailed benefit group from the list to modify it.

    If you are creating a detailed benefit that is similar to one that you have already created, click Copy to duplicate the plan, and adjust the details as needed. For information on copying maximum allotments, go to To copy detailed benefits.
  4. Select the Base information if required by the plan benefit:
    1. Select an attribute from the Attributes drop-down menu.
    2. Select a code from the Replace Code drop-down menu if the insurance carrier requires a code other than the standard CPT/HCPCS code.
    3. Select a modifier from the Modifier drop-down menu. After you record attributes with modifiers on fee slips, they appear in box 24D in the first modifier column on the CMS 1500 form.
  5. Select the Other 1 information if required by the plan benefit as needed:
    1. Select an attribute from the Attribute drop-down menu.
    2. Select a code from the Replace Code drop-down menu if the insurance carrier requires a code other than the standard CPT/HCPCS code.
    3. Select a modifier from the Modifier drop-down menu. After you record attributes with modifiers on fee slips, they appear in box 24D in the first modifier column on the CMS 1500 form.
    If the option to combine attributes for ready readers is selected on the plan Preferences tab, the Other 1 drop-down menus will not be available.
  6. Select a product group from the Product Group drop-down menu as needed.
    If the option to combine attributes for ready readers is selected on the plan Preferences tab, the Product Group drop-down menus will not be available.

    To add detailed benefit groups, go to To add & modify detailed benefit groups.
  7. Select the All Attributes Inclusive check box if products included in the product group with multiple attributes will should have all attributes included in the schedule of benefits.
  8. Click Save.
  9. Repeat steps 3–8 for each of the detailed benefits covered in the plan.
  1. Open the Detail Benefits window. For more information, go to To open the Detail Benefits window.
  2. Select Services from the Product Type drop-down menu.
  3. Click New to add a new detailed benefit group.

    OR

    Select a detailed benefit group from the list to modify it.

    If you are creating a detailed benefit that is similar to one that you have already created, click Copy to duplicate the plan, and adjust the details as needed. For information on copying maximum allotments, go to To copy detailed benefits.
  4. Select the Exam Cat./Base information if required by the plan benefit:
    1. Select an attribute from the Attributes drop-down menu.
    2. Select a code from the Replace Code drop-down menu if the insurance carrier requires a code other than the standard CPT/HCPCS code.
    3. Select a modifier from the Modifier drop-down menu. After you record attributes with modifiers on fee slips, they appear in box 24D in the first modifier column on the CMS 1500 form.
  5. Select the Type information if required by the plan benefit as needed:
    1. Select an attribute from the Attribute drop-down menu.
    2. Select a code from the Replace Code drop-down menu if the insurance carrier requires a code other than the standard CPT/HCPCS code.
    3. Select a modifier from the Modifier drop-down menu. After you record attributes with modifiers on fee slips, they appear in box 24D in the first modifier column on the CMS 1500 form.
    If the option to combine attributes for other is selected on the plan Preferences tab, the Other 1 drop-down menus will not be available.
  6. Select the Other 1 information if required by the plan benefit as needed:
    1. Select an attribute from the Attribute drop-down menu.
    2. Select a code from the Replace Code drop-down menu if the insurance carrier requires a code other than the standard CPT/HCPCS code.
    3. Select a modifier from the Modifier drop-down menu. After you record attributes with modifiers on fee slips, they appear in box 24D in the first modifier column on the CMS 1500 form.
    If the option to combine attributes for other is selected on the plan Preferences tab, the Other 1 drop-down menus will not be available.
  7. Select a product group from the Product Group drop-down menu as needed.
    • If the option to combine attributes for other is selected on the plan Preferences tab, the Product Group drop-down menus will not be available.
    • To add detailed benefit groups, go to To add & modify detailed benefit groups.
  8. Click Save.
  9. Repeat steps 3–8 for each of the detailed benefits covered in the plan.
  1. Open the Detail Benefits window. For more information, go to To open the Detail Benefits window.
  2. Select a product type from the Product Type drop-down menu.
  3. Click Group Builder.

    The Plan Group Builder window opens.

  4. Click New Group and type a name for the group in the Product Group field.

    OR

    Select a group from the Product Group drop-down menu.

    If you are creating a detailed benefit group that is similar to one that you have already created, even if it’s for different insurance plan, click Copy to duplicate the group, and adjust the details as needed. For information on copying detailed benefit groups, go to To copy detailed benefit groups.
  5. Click Find Product to find and add products to the group.

    The Find Product window opens.

  6. Type the first few letters of the name of the product(s) that you want to find in the Name field as needed.
  7. Select a manufacturer from the Manufacturer drop-down menu if it is available and if it is needed to refine your search.
  8. Select a designer from the Designer drop-down menu as needed.
  9. Click F2 Find to locate the product(s).
  10. Select the check boxes next to the product(s) that you want to add to the group.

    OR

    Click Check All to select all of the products in the results list.

  11. Click Select to save your selections.
  12. Repeat steps 6–11 to add additional products to the group as needed.
  13. Close the Find Product window when you are finished.
  14. If you need to remove any products from the list, select the check box next to the product name.
  15. Select a modifier from the Modifier drop-down menu, if desired. After you record groups with modifiers on fee slips, they appear in box 24D in the first modifier column on the CMS 1500 form.
  16. Click Save to save the Group.
    If you selected any check boxes in step 14, those products are removed from the group when the group is saved.
  17. Close the Plan Group Builder window.
  1. Open the Detail Benefits window. For more information, go to To open the Detail Benefits window.
  2. Select a product type from the Product Type drop-down menu.
  3. Click Group Builder.

    The Plan Group Builder window opens.

  4. Click Copy.

    The Copy Groups window opens.

  5. Select an insurance carrier from the Insurance drop-down menu.
  6. Select an insurance plan from the Plan drop-down menu.
  7. Select the check boxes next to the groups that you want to copy.
  8. Click Copy Selected.
  1. Open the Detail Benefits window. For more information, go to To open the Detail Benefits window.
  2. Click Copy.

    The Copy Detailed Benefits window opens.

    A confirmation may appear asking you if you want to overwrite any existing detailed benefits in this insurance plan. Select one of the following options:

    - Click Yes to erase all of the plan’s detailed benefits and replace them with those you are about to copy.

    - Click No to keep the current detailed benefits and not copy detailed benefits from another plan.
  3. Select an insurance carrier from the Select Carrier drop-down menu.

    All plans under that carrier with a detailed benefit pricing method appear in the results list.

  4. Select a plan from the list.
  5. Click OK.
  6. Modify the detailed benefits as needed.
  1. Open the Detail Benefits window. For more information, go to To open the Detail Benefits window.
  2. Click the Schedule of Benefits tab.
  3. Select a product type from the Product Type drop-down menu.
  4. Select a product from the tree.
    • Only those products or combination of products set up on the Detailed Benefits Setup tab appear in the tree. For information on setting up products on the Detailed Benefits Setup tab go to To add & modify detailed benefit groups.
    • If you are creating a schedule of benefits that is similar to one that you have already created, click Copy to duplicate the plan, and adjust the details as needed.
  5. Set the sequence in which products and services are paid under the plan by typing a number (between 1 and 5) in the Discount, Out of Pocket, Co-Pay, T/P Reimbursement, and Balance fields.
    • This is where you account for 100% of the product and service fees. All the fees charged by the practice will fall into these five categories: discount, patient out of pocket, copay, insurance reimbursement, and balance write off.
    • Enter the number in which each category should be executed in the sequence and type each number only once. For example, if the patient’s copay must be covered before any other calculations, type 1 in the Co-Pay field. If a discount must be applied to the entire balance before the copay is deducted from the total, type 1 in the Discount field and type 2 in the Co-Pay field.
    • Discount must be first in the sequence or last in the sequence depending on whether the discount is to be applied before or after.
    • Co-Pay must precede T/P Reimbursement in the sequence.
  6. For the Discount category, perform the following steps:
    1. Select the Before radio button if a discount should be applied to the balance before the patient payment or select the After radio button if a discount should be applied after the patient payment.
    2. Select the $ Amt radio button if the discount is a dollar amount or select the % Amt radio button if the discount is a percent.
    3. Type the amount or percent of the discount.
  7. For the Out of Pocket category, perform the following steps:
    1. Select the $ Amt, % Amt, Benefit, or Balance radio button depending on the insurance plan’s patient benefit.
      • The dollar and percentage amounts are amounts that may be specified by the insurance plan.
      • The Benefit amount is the patient’s allowance. The patient is responsible for any amount above the benefit amount.
      • The Balance radio button indicates that the patient is responsible for any amount above the third party reimbursement.
      • If you select the Balance radio button, the Out of Pocket category must be last in the sequence. Type 4 for the Out of Pocket sequence number and leave the Balance category blank.
    2. Type the amount or percent of the discount or type the amount of the patient’s benefit.
  8. For the Co-Pay category, perform the following steps:
    1. Select the $ Amt, % Amt, or Balance radio button depending on the insurance plan’s requirements.
      • The dollar and percentage amounts are amounts that are specified by the insurance plan.
      • The Balance radio button indicates that the patient is responsible for any amount above the third party reimbursement.
      • If you select the Balance radio button, the Co-Pay category must be last in the sequence. Type 4 for the Co-Pay sequence number and leave the Balance category blank.
    2. Type the amount or percent of the copay as needed.
  9. For the T/P Reimbursement category, perform the following steps:
    1. Select the $ Amt, % Amt, or Balance radio button.
      • The dollar and percentage amounts are amounts that are specified by the insurance plan.
      • The Balance radio button indicates that the insurance plan pays any amount above the patient’s copay and discount.
      • If you select the Balance radio button, the T/P Reimbursement category must be last in the sequence. Type 4 for the T/P Reimbursement sequence number and leave the Balance category blank.
    2. Type the amount or percent of the insurance reimbursement as needed.
  10. For the Balance category, select the Write-Off or Secondary -> W/O radio button, depending on the insurance plan’s requirements.
    • Select Write-Off to write off any balance not covered by the patient, insurance, or any discounts. The gap between the insurance plan’s coverage and the patient’s allowance is a balance that is typically written off.
    • Select Secondary -> W/O if the insurance plan allows you to bill a secondary insurance before writing off any balances not covered by the insurance or discounts. If this option is selected, and the patient has a secondary insurance that accepts transfers, a claim will be generated for the secondary insurance.
  11. Enter the maximum allowed by the insurance carrier for the attribute:
    1. Type the maximum copay in the Co-Pay text box.
    2. Type the maximum quantity in the Limit text box.
  12. Click Save to save the schedule of benefits.
  13. Repeat steps 3–12 for each product type.
  1. Open the Detail Benefits window. For more information, go to To open the Detail Benefits window.
  2. Click the Max Detail Benefits tab.
  3. Click New to add a product or combination of products to the maximum allowance list.

    OR

    Select a product or combination of products from the list to modify it.

    If you are creating a set of maximum allowances that is similar to one that you have already created, click Copy to duplicate the plan, and adjust the details as needed.
  4. Select a product type from the Product Type list.
    Select more than one product type from the list to create a combination. For example, many insurance plans have a different pricing structure for frames and ophthalmic lenses when purchased together than when purchased separately.
  5. If you selected multiple products from the Product Type list, select the Any or All Required Products radio button to chose whether any of the selected product types recorded on a fee slips are included in the combination or all of the selected product types recorded on a fee slip are included in the combination.
  6. In the Maximum Patient Allowance fields, enter the following information:
    1. Enter the patient’s allowance in the $ Amount field.
    2. If there is a limit to the quantity of this product type, enter the quantity in the Limit field.
  7. Type the maximum amount the insurance plan will pay in the Maximum T/P Reimbursement.
  8. Type the discount that the patient receives on any remaining balance over his or her allowance in the % Discounts Before/After Allowance field and select the Before or After radio button to specify if you want the discount to be applied before or after the allowance is applied.
  9. Type the patient’s copay in the Maximum Co-Pay field.
  10. Click Save to save your changes.

    The maximum allowance information is added to the tree on the left side of the window.

  11. Repeat steps 3–10 to add additional maximum allowance settings.