Open Dental Forum

I am trying to enter allowed amounts for a few codes that are being downgraded so that I can get estimates correct. I am newly in network w/Assurant. They are reducing 3S anterior composites to 2S and allowing me to bill the difference to the patient. I want the estimate for a 3S to be based on the 2S fee, and I thought I could use the allowed fee schedule to do that. I have Ins type set as PPO, selected the appropriate fee schedule, and then I am selecting the Appropriate Carrier allowed amounts (a fee schedule that reflects the downgrade, I have set the 2S fee as the 3S fee in this allowed schedule). Ins. estimates are still coming out wrong under the Treatment Plan Module.

Example
My fee Assurant fee (3S) Assurant fee (2S)
3S comp. 215 204 165

Ignoring deductible, the patient estimate for a 3S should be (165 x 20%) + (204-165)

But it is not working. The estimate under the treatment plan is still 204 x 20%

Any help would be appreciated.

Copying the reply I gave to your inquiry on Dentaltown about this subject, with numbers changed to match your example.

I believe this may work for you:
If the contracted fee for a 2 surface composite is $165, and the contracted fee for a 3 surface composite is $204, and the insurance company routinely downgrades a 3 surface to a 2 surface, then you would enter $165 as the fee for a 3 surface in the PPO fee schedule. Then you set up a Co-pay fee schedule for this PPO, and for a 3 surface composite you would enter a co-pay of $39 (the difference between the two fees that is the pt's responsibility). In the insurance plan edit window, on the left side where you select the fee schedules, you would need to add the co-pay fee schedule to each plan associated with this carrier. Hope that makes sense. In this case, this would give you a write off of $11, insurance coverage of 80% x $165, and a patient portion of 20% x $165 + copay of $39 (204-165). You just have to manually figure out what all of the copays will be, then enter them all in the copay fee schedule.