Improve the Accuracy of Patient Fee Estimates

Creating accurate insurance estimates can be a challenge. The Dentrix Payment and Coverage Tables can help. 

Accurate insurance estimates help patients understand what their out-of-pocket expenses will be. In Dentrix, most insurance estimates are fairly accurate right out of the gate. However, some procedures, such as posterior composites, often cause problems with insurance estimates. There are two tools in Dentrix that can help you improve the accuracy of your estimates for posterior composites and other procedures downgraded by insurance carriers: the payment table and the coverage table.

Using a Payment Table to Estimate Insurance Payment Amounts

The payment table is used to store the exact amount an insurance plan will pay for specific procedures. When you record insurance payment amounts in the payment table, those amounts will override any percentages you may have entered in the coverage table for the insurance plan, making the estimates more accurate.

To enter a procedure with its corresponding insurance payment amount into the payment table:

1. In the Office Manager, select Maintenance > Reference > Insurance Maintenance.

2. Select the plan you need to update the insurance estimate for and click Pmt Table.

3. Enter the procedure code (for example, D2393) in the Code field.

4. Enter the amount the insurance pays for the procedure in the Amount field (for example, $96 for a 200-composite downgraded to a $120-amalgam).

5. Click Add.

6. Click OK to return to the Insurance Maintenance dialog box.

Note: If you use the payment table to estimate what an insurance plan will pay for a procedure, because the estimate is based on a fixed dollar amount, you will have to manually update the payment table if the insurance plan increases or decreases the allowable fee for the procedure.

Using a Coverage Table to Estimate Insurance Payment Percentages

The coverage table is used to enter the percentage of your office fees an insurance plan will cover for a particular procedure or group of procedures. For example, the default coverage table for an insurance plan in Dentrix is set up with composites included in the Basic Restor category. All procedures within this group are usually covered at 80 percent and are based on the fee that posts to the Ledger.

You can customize a coverage table so that groups of procedures, such as posterior composites, are in their own category and covered at their own percentage. This allows Dentrix to estimate the insurance payment amount more accurately.

To separate posterior composites into their own coverage group:

1. In the Office Manager, select Maintenance > Reference > Insurance Maintenance.

2. Select the plan you need to update the insurance estimate for and click Cov Table.

3. Select the Basic Restor group and change the End Proc to D2390, the code just before the posterior composites begin.

4. Click Change.

5. Enter D2391 in the Beg Proc field and D2394 in the End Proc field. Enter “Posterior Comps” in the Category field. Change the Cov% to the percentage that the insurance plan usually pays for those procedures. (To calculate the percentage, divide the amount the insurance pays for the procedure by the amount you charge for the posterior composite.)

6. Click Add.

7. Enter D2395 in the Beg Proc field and D2699 in the End Proc field. Enter “Restorative” in the Category field. Enter 80 in the Cov% field.

8. Click Add.

9. Click OK to return to the Insurance Maintenance dialog box.

Note: If you use the coverage table to estimate what an insurance plan will pay for a procedure, because coverage is based on a percentage of your fee, not on a fixed dollar amount, you won’t have to update the coverage table if you ever increase your fees.

Whether you choose to use a payment table to estimate the fixed dollar amount an insurance plan will pay for a procedure or a coverage table to estimate what percentage of your fee the insurance plan will pay, it is important to have the information stored in Dentrix correctly so your insurance estimates are accurate. By using payment and coverage tables correctly, you will help your patients better know the amounts they are responsible for paying.


Learn More

To learn more about editing coverage tables or adding procedures to payment tables, see the Modifying Coverage Table Entries or Adding Procedures to the Payment Table topics in the Dentrix Help.

To get a free 30-minute practice assessment and get ideas to improve your insurance processes, visit www.Dentrix.com/ProfitabilityCoaching.


By Jennifer E. Blaser, Dentrix Profitability Coach

Originally published in Dentrix Magazine, Winter 2012