Insurance cover and estimates
Record who covers a patient, in what order, what benefit has been used this year, and estimate the insurance portion of planned treatment.
This section is for practices in the United States. It does not appear on the record of a practice in another country.
The Insurance section of the Account tab on the clinical record lists every coverage in claim order, with its plan, carrier, relationship and member number, cover dates and the benefit used this year. The row's icons — Check eligibility, Benefits used, End — carry the actions; hover one for its name. Claims sit under the same section.
Add cover
Click the + icon beside Insurance. Choose the subscriber:
- This patient (new subscription) — pick the plan and enter the member number. The patient is covered under their own subscription.
- Someone else's existing subscription — enter the member number and click Find, then pick the subscription. Use this for a dependant covered on a parent's or spouse's plan.
Set the relationship to the subscriber, the claim order (1 for primary) and the first covered day. Only one open coverage can hold each claim order; end the old one first when a patient changes plans.
Benefits used
Click the Benefits used icon on an open coverage to record what the carrier reports as already used this benefit year: the deductible met and the maximum used, per category. Estimates subtract these figures.
End cover
Click the End icon and enter the last covered day. The coverage stays on the record because estimates and claims cite it.
Estimate planned treatment
Click the Estimate planned treatment icon beside Insurance. Smileline reads the primary coverage's benefit design in force on the day and, for every planned procedure, shows:
| Column | Meaning |
|---|---|
| Fee | The practice fee on the procedure |
| Allowed | The plan's allowed amount when it keeps one, otherwise the fee |
| Covered | The percentage covered, or the copay |
| Deductible | The part of the allowed amount that goes to the deductible |
| Insurance | The estimated payer portion, capped by the remaining maximum |
| Patient | Fee minus the payer portion |
The notes column explains each figure: an exclusion, a downgrade, a waiting period, an age limit, a spent frequency, a reached maximum. The estimate stamps the benefit revision and payer portion on each procedure so the figures can be traced later.
An estimate is not a guarantee of payment. It reads the primary cover only; secondary and tertiary cover are coordinated on the claim, not in the estimate — see Insurance claims.
Account and payments
The patient's ledger on the clinical record — charges, payments (cash, card or on a card reader), refunds, adjustments, reversals, invoices, credit notes and period close.
Insurance claims
Build a claim from completed treatment, send it to the clearinghouse, check eligibility, and record what the payer answers.