The order of importance or priority of how Denticon calculates a fee for a procedure is listed below, with the item having the highest importance listed LAST:
1. Office UCR:
This is the default fee for a procedure if there is no other fee or fee schedule specified for a procedure for the current patient.
This is the default fee for a procedure if there is no other fee or fee schedule specified for a procedure for the current patient.
2. Fee Schedule assigned to the patient (e.g. UCR, staff UCR):
This is the fee schedule that is assigned directly to the patient chart. This fee is used if no other insurance or provider based fee schedule applies for this procedure for this patient.
This is the fee schedule that is assigned directly to the patient chart. This fee is used if no other insurance or provider based fee schedule applies for this procedure for this patient.
3. Fee Schedule assigned to a carrier (e.g. Delta Dental of California):
Each Carrier may be assigned to a fee schedule. All plans under this carrier will use this fee schedule as their baseline fee. This fee schedule is most useful for those insurance plans where all or some of their plans are based on a fixed fee, such as Delta Dental. A Delta Fee schedule may be attached to a carrier and all plans attached to this carrier will use the Delta Fees for their patients. This concept simplifies the maintenance of these fees since a single set of changes to a carrier record, will change all plans and patients attached to those plans.
Each Carrier may be assigned to a fee schedule. All plans under this carrier will use this fee schedule as their baseline fee. This fee schedule is most useful for those insurance plans where all or some of their plans are based on a fixed fee, such as Delta Dental. A Delta Fee schedule may be attached to a carrier and all plans attached to this carrier will use the Delta Fees for their patients. This concept simplifies the maintenance of these fees since a single set of changes to a carrier record, will change all plans and patients attached to those plans.
4. Fee Schedule assigned to specialty
Fee schedules assigned to a specialty will apply to any procedures posted to any provider assigned to that specialty without having to make individual assignments as long as no other assignments specifically made to those providers or providers and carriers and fee schedule is not assigned to the plan..
5. Fee Schedule assigned to a specific provider (typically a specialist):
Each provider may be assigned to a fee schedule. This is typically done with a specialist where her/his fees may be higher than that of the general dentist.
Each provider may be assigned to a fee schedule. This is typically done with a specialist where her/his fees may be higher than that of the general dentist.
6. Fee Schedule assigned to a carrier for a specific provider (typically a specialist fee schedule for a PPO):
Each provider may be assigned a specific fee schedule for a Carrier (PPO). This is typically done with a specialist where the PPO allows a higher than that of the general dentist or if specific fee schedules apply to the different providers in the office such as with certain carriers that have multiple tiers of reimbursement.
Each provider may be assigned a specific fee schedule for a Carrier (PPO). This is typically done with a specialist where the PPO allows a higher than that of the general dentist or if specific fee schedules apply to the different providers in the office such as with certain carriers that have multiple tiers of reimbursement.
7. Fee Schedule assigned to an insurance plan (e.g. Managed Care / Medicaid / PPO plans):
Each insurance plan may have a built in fee for a specific procedure. In these cases, the insurance fee over-rides all other fees that may be applicable for this patient.
Each insurance plan may have a built in fee for a specific procedure. In these cases, the insurance fee over-rides all other fees that may be applicable for this patient.
8. Fee Schedule assigned to a specific provider for an insurance plan (typically a specialist for an insurance plan).
**Note: These fees are procedure specific so that if there is no fee specified for a particular procedure for any of the above methods, the next method is used to calculate the fee. This is continued until all of the methods are exhausted (with the last method being the office UCR).
**Note: Each location may or may not have a specific fee schedule assigned for each of the categories listed above. If a location does not have a specific schedule assigned to the location, the system will use the default fee schedule for that item (e.g. carrier or plan).