To understand what fees are charged the patient, the user should refer to the question “hierarchy of fee schedule calculation.”
The order of importance or priority of how the program calculates a fee for a procedure is listed below, with the item having the highest importance listed LAST:
1. Insurance Plan Coverage Percentage:
The insurance estimation is based on the procedure code’s “Insurance Category” and the “% Coverage” for that Insurance Category of the insurance plan.
2. Alternate Minimum Benefit Code:
If an AMB Code exists within a Fee Schedule and a fee exists for that AMB code within the same fee schedule, the insurance estimation is based on the AMB fee and the coverage percentage of that AMB code. NOTE: The fee schedule type must be indicated as PPO- or Office-type.
Example: D2750P is for posterior crowns, and there is an AMB code of D2140. The fee for D2750 is normally $1000. The fee for D2140 is $200. The coverage percentage for D2140 is 80%. In this scenario, the insurance estimation for D2750P would be 80% of $200 ($160). The patient portion would be $1000 - $160 ($840).
3. Patient Co-Pay Fee Schedule:
If the Insurance Plan Type is “Indemnity” and there is a fee schedule attached to a plan that is of the type “Insurance-Patient Co-Pay,” the insurance estimation is the fee less the patient co-pay amount.
4. Insurance Fee Schedule:
Regardless of the Insurance Plan Type, if there is a fee schedule for that insurance plan, the insurance estimation is the insurance fee amount in the fee schedule.
NOTE: A fee schedule that is attached to a provider for an insurance plan takes preference over a fee schedule that is attached to an insurance plan.
5. Smart Fee:
If the insurance plan is attached to a Smart Fee schedule, the amount on the schedule is the insurance estimation.
**Note: If the patient information is indicated to “Assign Benefits to Patient,” the insurance estimation will always be calculated as $0.