How do we enter in a deductible?

The terminology and concept of “Deductible” must be understood first.

• The deductible is the amount of expense which the subscriber (aka: insured; aka: policy holder) must pay before benefits are covered by the insurance carrier.
• The deductible amount is covered 100% by the subscriber.
• The deductible is usually each benefit year dependent on the insurance plan’s anniversary year. While most dental insurance plans have a calendar year benefit period (January 1 through December 31), some insurance plans have a fiscal benefit year (i.e., April 1 through March 30).
• The deductible is applied to the patient’s first applicable procedure, according to the insurance plan setup.
• The deductible is always calculated first, before the estimated insurance amount is calculated.
• The deductible may be waived (aka: not calculated) for various dental categories.

Example #1: Deductible Waived Procedure

• Insurance plan setup:
  • $50 individual deductible
  • $2000 annual benefit
  • Deductible waived on Diagnostic procedures
  • Diagnostic procedures covered 100%
  • D0120 – Periodic Oral Evaluation = Diagnostic procedure
  • Fee = $85
  • Estimated insurance = $85
  • Estimated patient = $0

Example #2: Deductible Not Waived Procedure

• Insurance plan setup:
  • $50 individual deductible
  • $2000 annual benefit
  • Deductible not waived on Restorative procedures
  • Restorative procedures covered 80%
  • D2391 – Resin Composite One Surface Posterior = Restorative procedure
  • Fee = $200
  • Estimated insurance = $120
  • Estimated patient = $80
  • Calculation:
    • $200 fee - $50 deductible = $150
    • $150 x 80% = $120 estimated insurance
    • $200 fee - $120 estimated insurance = $80 estimated patient

Example #3: Deductible Not Waived Procedure – 2 Procedures

• Insurance plan setup:
  • $50 individual deductible
  • $2000 annual benefit
  • Deductible not waived on Restorative procedures
  • Restorative procedures covered 80%
  • D2950 – Core Buildup Including Pins = Restorative procedure
  • D2950 Fee = $200
  • D2740 – Crown Porcln/Cer Substrate = Restorative procedure
  • D2740 Fee = $1200
  • Total Fees = $1400 ($200 + $1200)
  • Estimated insurance = $1080 ($120 + $960)
  • Estimated patient = $320 ($80 + $240)
  • Calculation – D2950:
    • $200 fee - $50 deductible = $150
    • $150 x 80% = $120 estimated insurance
    • $200 fee - $120 estimated insurance = $80 estimated patient
  • Calculation – D2740:
    • $1200 fee - $0 remaining deductible = $1200
    • $1200 x 80% = $960 estimated insurance
    • $1200 fee - $960 estimated insurance = $240 estimated patient