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 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: 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.