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Canine II

## How to set up coverage book Practice works for Premier Delta Dental to estimate PPO correctly

Premolar II

Does anyone have the best way to calculate the copay when the Approved amount and Allowed amount are different, to calculate to the penny. This would be for mostly of Delta Dental plans when the office is a Premier Provider and the plan is PPO. I have always been told to divide the PPO payment into the Approved amount to receive the percentage.

Billed Fee  Allowed    Approved    Ded     O-Visit   CoPay   Pt Pmt     Plan Pmt

 \$46.00 \$32.00 \$26.00 \$0.00 \$0.00 80% \$11.20 \$20.80

The formula/recommendation works well for this fee, 20.80 divided by 32 = 65%

In the case of other amounts, it results in calculations that are not exact, therefore the collected amount will either result in overpayment or underpayment, as in the following example (which is only pennies but this should be able to be programmed to calculate to the penny) .

Billed Fee   Approved  Allowed  Deductible O-Visit  CoPay   Pt Pmt    Plan Pmt

 \$121.00 \$98.00 \$80.00 \$50.00 \$0.00 30% \$89.00 \$9.00

For demonstration, the deductible is not used to calculate the % that would be placed into insurance calculation.

30%x \$80 = \$24    \$24 divided by \$98 = 24.4897959%    \$98 x 24.49% = \$24.00

PW will not pick up two decimal places so the options are: 24.4 or 24.5.

\$98 x 24.4% = \$23.91    OR       \$98 x 24.5% = \$24.01

The only way to have exact calculations is to have change the formula to:

Approved Amount - (Allowed Amount x Copay %) = Patient Payment

\$98 - (\$80x30%) = \$98-\$24 = \$74.00    Exact to the penny.   No extra time to send a 1st, 2nd statement, no confusion for staff or patient.

I don't want to have to refer to a binder for exact calculations. If that is the case, then why have PW?

HI! Are you able to set this up in the coverage book somehow ? If so PLEASE show me how.

Thanks

Moderator

Sorry, I was out of the office all of last week, however, I can set up a tie this week if you'd like to go over the basics of Insurance estimating setup.  It would also be possible for you to set up some time with one of our trainers if preferred.

Johnathan Downer | Technical Support Analyst
Moderator

The insurance estimating would be set up within each employer/plan that is connected to the Premier Delta Dental insurance company profiles.

I have attached a PDF that goes over the insurance estimating setup in the CS PracticeWorks software that you can save to your computer.   If you need additional assistance we can schedule a time for one of our Representatives to give you a call or you would be welcome to give support a call at your convenience.  You can find our support phone number here.

Johnathan Downer | Technical Support Analyst
Canine II

Good Morning! This is the issue how am I to set up the coverage book with for patient pays portion? We write off the Premier fee but then the PPo allowance is obviously lower and that goes to patient to pay. I honestly do not think that Practice Works program allows this set up. Please let me know is anyone knows.

Moderator

I focused my setup only on the 0120 code, but they would all be set up similarly.   Based on the EOB, this is how I set up my code-specific estimating for the 0120

Patient payment Method = 3 Set to 10.00 (patient pays column on EOB)
Insurance payment method = Fixed amount set to 38.00 (Amount ins paid on EOB)

No need to enter the Max Fee (UCR)/Ins fee due to setting the fixed amount for insurance.

the software will automatically calculate the write-off based on what is left over after the insurance and patient payment are subtracted from the office fee.

Johnathan Downer | Technical Support Analyst
Premolar II

I have asked the same and unfortunately unless a "binder" is created or manually estimating is the only way. Premier is a higher tier reimbursement than PPO. PPO plans have an approved amount and Premier is the allowed amount. Patient pays the difference between the approved and allowed. Below is the issue that I posted in the past.