Introduction
From time-to-time users may notice that the incorrect fees are showing when either trying to treatment plan or post treatment to the ledger. The following guide will help troubleshoot the most common causes of this issue.
Issue description
When fees are not calculating correctly the user may notice incorrect fee amounts populating in the estimated patient and insurance portions of the treatment plan or ledger. The user may also notice no insurance portion when there is an insurance plan attached to the patient.
Signs
Incorrect fee amount in the estimated insurance portion of the ledger or treatment plan.
No estimated insurance amount in the estimated insurance portion of the ledger or treatment plan.
Basic troubleshooting steps
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For incorrect fees:
- Go to the Patient Overview Screen, click the group number of the patient's insurance plan to view the insurance plan setup. Navigate to the coverage and limitations section of the insurance plan setup to verify the plan is setup with correct coverage percentages. Verify that the deductible waived setting for each category is correct.
- Go to Setup>Procedures Codes to verify the Insurance Category associated with the code is correct.
- If the patient no longer has insurance but is showing insurance coverage when there should not be, check the billing order on the procedure code to ensure no billing order is attached. (D or DD in the Bill column.)
- From the Patient Overview screen, click "Primary" or "Secondary" to view the primary or secondary dental plan setup.
- Does the setup indicate the correct remaining individual and/or family annual deductible?
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When $0 estimated insurance is occurring:
- Got to the Patient Overview Screen and click "Edit". Is “Assign Benefits to Patient” active (checkmark is in the box)? When this setting is marked, the office doesn't need to generate a claim for the patient in order for the patient to receive the insurance reimbursement, so there will be an estimated ins amount of $0 indicating insurance payment to the office is not expected.
- From the patient overview screen, click the blue link in the Group number field of the primary or secondary plan. What is the insurance plan type set to? If the plan type is set to NHS, no insurance fees will populate. This plan type is for our customers living in countries where there is a National Health Service.
- From the Patient Overview screen, click "Primary" or "Secondary" to view the primary or secondary dental plan setup.
- Check to see if insurance plan is setup with correct individual and/or family annual benefit maximums. If there is $0 in the family max remaining, the system will show $0 insurance coverage. If a family max should not be considered for the plan, enter $99,999 so the amount never runs out during the year which functions the same as the max not being considered.
- Has the patient met their annual maximum for the year? If there are no benefits remaining, a code may show no insurance responsibility.
- Check the billing order on the procedure code, is there a D or DD in the Bill column? If there is not, click the date of the procedure code, click the button labeled as "Advanced", and switch the billing order from "None" to "Dental".
- From the Setup menu, select Procedure Codes and then Procedure Codes again. Search your code in the Search Text box and click on the code. Check to be sure that the 'Ins. Billing Order' field is not set to "Do not bill to Insurance". If it is, press Edit and select an option like "Bill to Dental Insurance", etc. Press Save to confirm.
Advanced troubleshooting steps
- Review that the correct fee schedule is being applied.
- Click into the date of the procedure code in either the treatment plan or ledger. Note the fee schedule being used.
- If the incorrect fee schedule is being used:
- If the plan should be a PPO, check insurance plan type in the insurance plan setup screen, then view the carrier setup to see if a PPO type fee schedule is attached to the contracted insurance carrier. Make sure there is only a fee schedule assigned to the insurance carrier and not the plan.
- If the plan is a managed care plan, check insurance plan type in the insurance plan setup screen, then view the insurance plan setup to see if a managed care type fee schedule is attached to the contracted insurance plan. Make sure there is only a fee schedule assigned to the insurance plan and not the carrier.
- Go to Setup>Fee Schedules>Fee Schedule Assignments
- Filter fee schedule assignments by provider to view fee schedules attached to treating provider.
- Is there a different fee schedule for that specific carrier/plan+ office + provider assigned?
- Filter fee schedule assignments by office to view fee schedules attached to treating office.
- Is there a different fee schedule for that specific carrier/plan+ office assigned?
- Filter fee schedule assignments by Fee schedule and select the office UCR, review to ensure that the UCR fee schedule is not improperly assigned to the treating provider, insurance carrier, or insurance plan.
- Filter fee schedule assignments by provider to view fee schedules attached to treating provider.
- If correct fee schedule is being used but the fee is still wrong:
- Go to Setup>Fee Schedules>Fee Schedule Setup and select the fee schedule.
- Is the correct fee entered for the procedure code? If there is not a fee entered, Denticon will pull the office's UCR fee for the same procedure code.
- Check to see if the fee schedule has an AMB code listed for the procedure.
- Go to Setup>Fee Schedules>Fee Schedule Setup and select the fee schedule.
Contact support
If you have exhausted these troubleshooting steps and still cannot determine why the incorrect fee is showing, please submit a ticket to Denticon Support. Provide the patient name/ID as well as the name of the correct fee schedule that should be showing, and an agent will review as soon as ticket volume allows.
Additional resources
Please note: Managed Care is the same term as Capitation, Medicaid, HMO, DHMO
How may a fee schedule be assigned to a particular provider or a particular office?