Insurance Estimation Engine
Hybrid Plans will have two fee schedules attached. One to the Insurance Carrier, the maximum allowable and another attached to the Insurance Plan, the “cut back". But to keep the normal Denticon nomenclature, the Fee Schedule type for both attachments will be Ins – PPO. The plan type must be indicated as a 'Hybrid Plan'.
If a procedure code does not have an associated PPO fee, the system will use the fee on the next level according to the Denticon fee calculation hierarchy.
Hybrid Plans base the total fee on the PPO fee schedule assigned to the carrier but base the insurance coverage for that plan on the PPO fee schedule attached to the plan.
The system will use the plan’s coverage percentages to calculate the insurance coverage based on the PPO fee schedule assigned to the plan (the cut back fee) and the patient portion will be the difference between the two fees.
A sample of a typical coverage is below:
In a Hybrid Plan the total fee is the total charged for the procedure. The insurance coverage is based on the Cutback fee and the Coverage %.
So in this example the following is the estimate.
Ins Est = Cutback Fee * Coverage %
56.00 = 70.00 * 0.80
Pat Est = Total Fee – Ins Est
64.00 = 120.00 - 56.00
Please Note:
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. The Hybrid option would only work with Primary Insurances since it doesn't consider the Secondary Fee Schedule fees.