1. Confirm the inputs
Confirm eligibility using your normal process and use the applicable benefit report. Record the chosen frame, lens design, material, coatings, and extras using your practice’s current prices. Check that you are quoting the selection the patient actually wants.
2. Work through the frame benefit
When the report specifies an allowance and a percentage discount on the remaining overage, calculate the eligible overage first and apply the stated discount only to that amount. Do not assume every plan uses this structure.
In the sample shown on this site, a $250 frame minus a $180 allowance leaves $70. The example’s 20% overage discount reduces that amount by $14, leaving $56. Frame brand conditions in that example must also match.
3. Add the applicable lens and copay lines
Check the base lens benefit, selected material, each treatment or enhancement, and any materials copay. Some lines may be zero in one report and chargeable in another. Do not count a charge twice or apply a blanket percentage discount unless the report supports it.
The site’s worked example adds $0 single vision, $35 polycarbonate, $85 ZEISS Platinum, $25 materials copay, and $10 UV backside. Those $155 of additional charges plus the $56 frame responsibility produce a $211 estimate. Exam fees are excluded.
4. Explain what is included
Name the selected frame and lenses, point out the benefit amounts used, and identify anything excluded. A patient changing the frame or lens options should receive a revised estimate. Clarify any applicable taxes or additional services through your practice’s billing process.
5. Review before completing the sale
- Does every benefit figure match the source report?
- Are the selected products eligible for the applied pricing?
- Are promotions permitted with this specific benefit?
- Have unclear details been resolved and final coverage confirmed?
Use software to make the review easier
OptiAlly reads supplied reports and applies configured practice pricing to help build an itemized estimate. Staff still review the source and final pricing. This guide illustrates a process, not universal plan rules.