How to Add or Update Patient Insurance

For customers in the United States, Sensei Cloud supports an unlimited number of patient insurance plans. Each patient can have one Primary, one Secondary, and multiple plans designated as Other. 

A patient's associated insurance policies are visible from the Patient Snapshot, the Patient Home Page, and the Patient Record.

Note: When submitting claims for a set of charges, it is recommended that you submit to Primary insurance first and await a response, and then submit to Secondary.

IMPORTANT: 
-- When updating a patient's insurance, be sure to make all changes from the Insurance Information section in the Patient Record. If you are accessing the Update Insurance Policy window, keep in mind that clicking the Associate Plan blue hyperlink launches the Update Insurance Plan window, and any changes will apply a mass update to the insurance plan, thus affecting all patients that subscribe to the plan. 
-- The Update Insurance Plan window or Update [Insurance Payer] windows should not be utilized for updates that are specific to a single patient, as changes made from these windows affect every patient enrolled in that insurance plan. 

Adding a Patient Policy

To enter an insurance policy for a patient:

1. From the Patient tab, select Patient Record, and then click Edit Patient Record.
2. Under Jump To, click Insurance Information. The patient's existing policies are listed, along with the Group #, Subscriber ID, Status, and Type for each.
   Note: You can also access this section of the Patient Record using the Update Insurance button on the Home page. You can edit or remove plans as needed, and then click Update.
3. Select Add Insurance Policy. The Create Insurance Policy window is displayed.
   
4. For Coverage, select Primary, Secondary, or Other. 
   Note: If you select Primary when adding a second policy, the previous Primary policy becomes Secondary.
5. Select the Policyholder and Patient Relationship to Policyholder if the policyholder is not the patient (Self). 
   Note: If the selected policyholder does not have a defined address, a message is displayed. You are prompted to update the associated record or to make the update later.
   
6. In the Associated Plan field, start typing the name of the plan you want to enter. If the plan is in the system, select it from the list.
   Note: 
   -- If the plan is not in the list, you are prompted to create it. For more information, see Creating a New Insurance Plan.
   -- You can also search for a plan by the associated zip code.
7. Enter the Subscriber / Member ID number and Effective Date of the policy.
   Note: Effective Date defaults to the first of the year, but can be edited. This date must fall on or before the service date of the procedures to be billed.
8. For Assignment of Benefits, select Assigned if the insurance company reimburses the provider directly, or Not Assigned if reimbursement goes to the patient.
   Note: This value is reflected in Box 37 of the ADA Claim form. When Assigned is selected, Box 37 automatically displays Signature on File and the current date when the claim is printed. When Not Assigned is selected, Box 37 is left blank.
9. Select the Eligibility / Status: Active, Inactive, or Unverified.
10. Enter the Deductible Remaining and Benefits Remaining amounts.
    Note: These amounts impact the insurance estimation calculation and must be manually updated to ensure that insurance estimation is accurate. The values default based on the associated plan, but if the plan is set to $0 or if the patient's policy details are modified to $0 (or other small amount), then the estimated insurance coverage will inaccurately display as $0.
11. Enter the Ortho Benefits Remaining amounts, if applicable.
    Note: The starting values are derived from the insurance plan's defined ortho benefit values.
12. Click Create.
13. Click Save Patient.

Editing Patient Insurance

IMPORTANT: 
-- When updating a patient's insurance from the Patient Home, click the Update Insurance button to open the Patient Record and make any changes in the Insurance Information section (i.e., remove, edit, inactivate, or add insurance policies for the individual patient). 

-- Clicking the Insurance Plan/Payer blue hyperlink next to Plan (Payer): opens the Update Insurance Plan or the Update [Payer Name] window. Any updates made from these windows update the insurance plan or payer for ALL patients that are enrolled in the plan. Do NOT use this window for insurance updates for individual patients.

To edit a patient's insurance:

1. Navigate to the Patient Record by selecting Patient > Patient Record > Edit Patient Record or by clicking Update Insurance from the Patient > Home. The Patient Record is displayed. 
2. Scroll to the Insurance Information section. The patient's existing policies are listed, along with the Group #, Subscriber ID, Status, and Type for each.
3. Edit, inactivate, remove, and/or add policies as needed. 
   Note: If you click Edit, the Update Insurance Policy window is displayed. Make any necessary changes to the patient's policy (e.g., changing coverage to Secondary, etc.), and then click Update to save.
   
   IMPORTANT: 
   -- When accessing the Update Insurance Policy window, clicking the Associated Plan blue hyperlink opens the Update Insurance Plan window. Any changes made from this window impact ALL patients enrolled in the plan. If the change you are making does not apply to all patients, click Cancel to exit the Update Insurance Plan window. 
   -- For example, in some cases, rather than editing the patient's existing policy, you may need to inactivate it and then create a new policy to assign the patient to. 
   Note: 
   -- To inactivate a patient's policy: From the Update Insurance Policy window, next to Ineligibility Status, select Inactive, and then click Update. The policy remains listed in the patient's record, but the status is changed to Inactive. 
   -- To add a new policy: Click Add Insurance Policy, and the Create Insurance Policy window is displayed. Add the policy details and click Create to add it to the patient's record. 
   -- You can also select Patient is Not Covered by Insurance if the patient does not have any active insurance coverage. When this option is selected, a red PRIVATE PAY PATIENT banner is displayed on the Patient Home under Insurance. 
4. Click Save Patient to save the changes to the Patient Record.

Creating a New Insurance Plan

There are two places to enter a new plan into your system:

• When adding patient insurance, you are prompted to create a plan that is not already in the system. Click Create PlanName.
• From the Administration tab, select Insurance > Plans, and then click Add New Plan.

The Create New Insurance Plan window is displayed.

1. Select the Plan Type: Dental or Medical. 
   Note: 
   -- If Dental, there is an ADA Paper Claim Format option for the 2019 Form or 2024 Form. Any new plans added going forward default to the 2024 claim form. 
   -- If Medical, you are prompted to select the Medical Insurance Type.
2. Complete the Plan Information section: Contracted, Name, Payer, and Group Number.
3. For Contact Information, enter the details if different from the Payer.
   Note: You can also enter notes for the insurance plan in the Notes field.
4. Enter a URL in the Eligibility Website field if the Insurance plan has provided one.
   Note: This creates a hyperlink on the Patient Home page that can be used to quickly verify patient eligibility.
5. Scroll down to the Fee Coverage Information.
   
6. Enter the Coverage Information details and Monetary Limits.
7. For practices using contracts, set the default Ortho Charge Frequency (Monthly, Quarterly, etc.) to populate the Frequency field for new charge schedules.
   Note: This value is editable in the schedule.
   Note: If the payer/plan does not require or accept Continuation of Treatment (COT) claims, select COT Claims Not Required.
8. For practices using the Orthodontic treatment functionality, enter the Ortho Allowable Benefit amounts.
9. Click Create. The plan is added to the list of insurance plans for the practice, and can be managed from the Insurance Plans window (Administration > Insurance > Plans). 

Updating an Insurance Plan

IMPORTANT: Updates made to the Insurance Plan affect ALL patients that have insurance coverage through the plan. It is important to confirm that any updates you are making to an Insurance Plan apply to everyone enrolled in the plan before saving your changes. 

To update an insurance plan:

1. From the Administration tab, select Insurance > Plans. A list of insurance plans is displayed.
2. Click the Plan Name. The Update Insurance Plan window is displayed.
   
3. Update the information as needed.
   Note: If the plan is a Dental plan, there is an ADA Paper Claim Format option where you can select to use the 2019 Form or 2024 Form. Existing plans default to the 2019 ADA claim form, but any new plans added going forward default to the 2024 claim form.
4. Click Update.

For more information, see How to Set Coverage Details and Benefits by Category on an Insurance Plan.

Viewing Patients Associated with an Insurance Plan

You have the ability to view a list of patients that have insurance policies linked to an insurance plan from the Insurance Plans List (Administration > Insurance > Plans).

To view a list of the patients who are associated with an insurance plan:

1. From the Insurance Plans List, scroll to the line item for the insurance plan.
2. From the PTs column, click the [Number of Patients] hyperlink. A list of patients is displayed, along with their total balance and their status (i.e., whether they are an active or inactive patient).
   
3. Click on the Patient Name to open the Patient Snapshot. You can then navigate to their record or take any other needed actions.