When an office is contracted with an insurance carrier, there is an anticipation that the contracted fees will be covered per:
- the insurance carrier’s contracted fee schedule
- the plan’s standard coverage percentage
Sometimes, the individual plan does not cover tooth-colored restorations on posterior teeth (i.e., crowns, surface fillings). The downgraded insurance coverage should be calculated on the downgraded procedure fee. For these plans, there should be an alternate ADA code used when posting completed procedures; and the fee schedule should be setup to easily calculate the different coverage.
Procedure Code Setup
Before a fee can adequately be entered as an AMB, a new code must be setup in the procedure code setup screen that matches the procedure code for which an alternate minimum benefit is indicated. NOTE: Information regarding setting up procedure codes is available within the Help Portal.
The new code should exactly duplicate its normal ADA code, but should have an identifying sub-letter so everyone in the office will know to select the sub-lettered code for plans in which the insurance carrier will downgrade the procedure. Only the standard ADA portion of the code will print on the insurance claim form. Example: the existing code for a resin composite one-surface restoration on a posterior tooth is D2391. The newly created code for AMB usage should be D2391x, where x is an office defined sub-letter; any letter may be used. When either code is used in a patient record, the full code used will show in the patient ledger and/or treatment plan. When the insurance claim form is generated, only the “standard” portion of the ADA code (i.e., D2391) will print.
The standard and the alternative codes should be active within the “Setup / Offices” screen in order to allow office users to select the correct procedure code for treatment planning and posting.
Once the procedure code is setup, the fee schedule must show that an AMB is available for usage. The ADA code that will be used for the downgrade is indicated in the AMB column. NOTE: Information regarding adding fee schedules is available within the Help Portal.
Fee Schedule Setup
In order to have the contracted fee posted correctly, as well as the correct estimated insurance and patient portions calculated, the fee schedule should be setup for Alternative Minimum Benefits (AMB).
A column in the PPO-type and the Office-type fee schedules allows for such a situation. The column is marked “AMB” for Alternative Minimum Benefit.
NOTE: The AMB column is intended for usage within “Insurance – PPO” fee schedules. The AMB column is not available for smart fee-type (aka: indemnity) schedules nor for capitation/managed care-type fee schedules.
The calculation of the fee is exactly as same as for a PPO or Office fee. If there is a fee amount for the procedure, Denticon will calculate the charge and coverage for the indicated fee. If there is not a fee indicated in the schedule for that procedure, Denticon will utilize whatever is considered as the next fee, according to the fee hierarchy.
If the procedure code has an AMB fee amount, the coverage calculation is modified to the following:
The AMB fee is utilized for the code’s calculation, used as the “base fee” for coverage calculation
Example: D2750 uses D2394 as the alternative benefit. The fee for D2750 is $800, and D2394 is $200. Denticon will look at the Benefit percentage of the D2750 code (for this example, assume the percentage to be 80%).
Ignoring the calculation of applicable deductibles for this example, the insurance would cover 80% of $200; this is $160.
Denticon then calculates the patient portion as (Total Fee - Insurance Estimate). Which, in this example, is calculated as $800 - (0.8*$200) = $540.
If there is not an amount in the AMB column but there is an amount in the fee column, the calculation will be based on the amount found in the fee column.
If there is not an amount in either column, the fee calculation will be based on Denticon’s fee hierarchy.
NOTE: Only the ADA Code should be entered within in the AMB column. There should not a financial amount entered into the procedure’s AMB field.
NOTE: It may be necessary to set up a new code for the AMB. Please consult the question in the Fee Schedule section that provides guidance on the set up of procedure codes (Help / Online Library / Procedure Codes / Procedure Codes / add procedure code).
Insurance Plan Setup
It is recommended to input notes within the insurance plan setup, indicating that the alternative code should be used for the patients who are assigned to the plan.
Additionally, it is recommended to enter a flash alert on the patient’s record, bringing attention to the user for the need to use the alternative procedure code.