Fee Schedule Logic

See Procedure Codes.

The Fee Schedule used for procedure fee estimates is determined using the logic below.

Insurance

If the patient has insurance, the fee schedule of the first insurance plan listed in the Family module is used (e.g. order = 1 on the Insurance Plan).

If the insurance is a PPO plan that has two fee schedules (PPO fee schedule and Provider fee schedule), the procedure fee is based on the fee schedule that has the higher fee.

No Insurance

(rare) If there is no insurance and a fee schedule is set for the patient in the Edit Patient Information, this fee schedule is used.

Otherwise, for patients without insurance, the fee schedule of the provider who has priority is used.

Medical

If the patient has medical insurance, the fee schedule of the first medical insurance plan listed in the Family module is used.

If a Procedure Code is a dental code cross-coded to a medical code, then the setting in Chart Module Preferences for Use medical fee for new procedures determines the fee. If checked, the fee of the medical code is used; if unchecked the fee of the dental code is used.

Overrides

After the fee schedule is determined, then any Provider and/or Clinic-Specific Overrides are applied to that fee schedule.