Let's explore an alternate insurance plan setting called non-covered codes.
This is only applicable to Dental PPO, Dental Indemnity, and Dental Co-Pay Plan Types.
Check out this resourceful video for a comprehensive walkthrough
Non-Covered Codes are codes that a particular insurance plan will never cover. You can choose whether to bill UCR or Max Allowable for such codes on a plan-by-plan basis.
This setting would apply to a procedure code in any of the following criteria:
- Non-Covered Procedure Codes: When a procedure code has 0% coverage or is missing from the Code Coverage Categories. (Applicable to PPO and Indemnity plan types.)
- TOA (Table of Allowance): When the TOA for insurance amount for a Co-Pay Plan is $0 for a Procedure Code.
- Fee Register: When a procedure code is listed as $0 under the Fee Register if it is enabled. (Applicable to PPO, Indemnity, and Co-Pay plan types.)
You can set the fee for Non-Covered Codes in the practice settings on a plan-by-plan basis.
| Tip: UCR stands for 'Usual, Customary, and Reasonable' which refers to the office fee amount paid for a medical service in a geographic area, usually based on what similar providers in the area charge for the same or similar medical service. |
Let's get started!
Configure Fee for Non-Covered Codes
Perform the steps below to configure the Non-Covered Codes Fee.
- Navigate to the System Menu > select Practice Settings > Insurance Manager > Plans.
- Click the intended insurance plan.
- Click Details > Edit.
- Under Fee Related Settings, select UCR for Fee for non covered codes setting.
- Click Save.
The UCR fee will be charged based on the criteria mentioned above. Here are some examples:
Examples
Scenario 1:
When you check for Coverage in an insurance plan, some codes or coverage categories may have 0% coverage on the insurance plan.
- When the fee for non-covered codes is set to UCR, you can check the CodeStack for the corresponding code, where you will see that the Current Fee (UCR) is higher than the Estimated Fee (Max Allowable).
- This process also applies to the Additional Coverage items.
Scenario 2:
- When you check a patient’s Fee Register, you may see some codes with $0 as the Insurance Amount.
- When you check the CodeStack for the same code, you will see that the Current Fee (UCR) is higher than the Estimated Fee (Max Allowable).
| Note: For UCR to be applied in the scenario above, the Fee Register must be enabled. |
Scenario 3:
When a code is listed as $0 for a Co-pay Plan Type, you can see that the Current Fee (UCR) is higher than the Estimated Fee (Max Allowable).
| Note: The Table of Allowance must be set to the Insurance Amount in the Plan Settings for the scenario above. |
Check out this article by the American Dental Organization to learn which states are allowed to charge UCR on non-covered codes and how insurance contracts affect this decision.
Practices can use this simple guide to learn how to configure the fee setting for Non-Covered Codes.