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 this is in red, there are some procedure codes in the category that have a different percentage. 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 AmountUsed — the amount used to date by the individual
• Individual AmountRemaining — the amount not yet used by the individual
• Family — the limit for a family (all members under a subscriber)
• Family AmountUsed — the amount used to date by the family
• Family Amount Remaining — the amount not yet used by the family
• 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

COB Information

Coordination of Benefits (COB) occurs when a patient is eligible for benefits under multiple contracts or multiple payers.

Information such as COB Payment Order, and COB Payment Option Type appears.

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