Denticon’s programming follows only the American Dental Association’s (ADA) “Coordination of Benefits” definition (below)
Denticon does not calculate “Non-duplication of Benefits”
The primary insurance fee is used for the procedure fee. Secondary insurance fees are not considered for calculation.
Example #1 –
patient has primary and secondary insurance
each insurance plan is “Indemnity” type
each insurance plan has $50 deductible
each insurance carrier has unique fee schedule – secondary fees are higher
procedure fee = $100 (primary fee schedule)
80% insurance coverage on each plan
deductible for each plan is calculated in estimated patient portion
primary – $50 deductible applied – 80% coverage is $40 estimated insurance portion
secondary – $50 deductible applied – 80% coverage is $40 estimated insurance portion
Total estimated insurance is $80 = primary ins estimate($40) + secondary insurance estimate($40)
Total estimated patient is $20 = estimated insurance portion($80) - procedure fee($100)
Example #2 –
patient has primary and secondary insurance
primary insurance plan is “Indemnity” type, and secondary insurance plan is “Managed Care” type
primary insurance plan has $50 deductible
secondary insurance plan has $0 deductible
primary insurance carrier has unique fee schedule
secondary Managed Care plan has unique fee schedule
procedure fee = $100 (primary fee schedule)
80% insurance coverage on each plan
deductible for each plan is calculated in estimated patient portion
primary – $50 deductible applied – 80% coverage is $40 estimated insurance portion
secondary – $0 deductible applied –coverage is based on insurance fee schedule which has a $5 patient co-pay, and $10 insurance supplemental reimbursement
Total estimated insurance is $50 = primary ins estimate($40) + secondary insurance estimate($10)
Total estimated patient is $50 = estimated insurance portion($50) - procedure fee($100)
Example #3 –
patient has primary and secondary insurance
primary insurance plan is “Managed Care” type, and secondary insurance plan is “Indemnity” type
primary insurance plan has $0 deductible
secondary insurance plan has $50 deductible
primary Managed Care plan has unique fee schedule
secondary insurance carrier has unique fee schedule
procedure fee = $15 (primary fee schedule, the total of patient co-pay and supplemental reimbursement)
primary estimated insurance is supplemental reimbursement amount
secondary estimated insurance applies toward patient co-pay amount
Example #4 –
patient has primary and secondary insurance
each insurance plan is “Managed Care”
each insurance plan has $0 deductible
each insurance plan has 0% coverage
each insurance plan has unique fee schedule, same fees on each schedule
procedure fee = $15 (primary fee schedule, the total of patient co-pay and supplemental reimbursement)
primary estimated insurance is supplemental reimbursement amount = $10
secondary estimated insurance is supplemental reimbursement amount, up to the remaining fee amount = $5
NOTE: Denticon’s programming follows only the ADA’s “Coordination of Benefits” definition. Denticon does not calculate “Nonduplication of Benefits”
Per the American Dental Association (ADA) Current Dental Terminology: The ADA Practical Guide to Dental Procedure Codes) [CDT] –
Coordination of Benefits (COB) – A method of integrating benefits payable for the same patient under more than one plan. Benefits from all sources should not exceed 100% of the total charges.
Nonduplication of Benefits – Term used to describe one of the ways the secondary carrier may calculate its portion of the payment if a patient is covered by two benefit plans. The secondary carrier calculates what it would have paid if it were the primary plan and subtracts what the other plan paid. For example, if the primary carrier paid 80 percent, and the secondary carrier normally covers 80 percent as well, the secondary carrier would not make any additional payment. If the primary carrier paid 50 percent, however, the secondary carrier would pay up to 30 percent.