How to calculate a dental patient portion

For each treatment line, in the order you added them:

1. Start from the allowed fee. In network, the insurer's contracted fee from your price list. Out of network, the plan's usual fee if staff typed it, otherwise your own fee.
2. Apply any downgrade. If the plan pays this service at a cheaper service's rate, use that lower fee.
3. Zero the line if a rule says the plan won't pay: not covered, waiting period not over, frequency limit reached, or the missing-tooth rule.
4. Take off the deductible left. Preventive care skips the deductible, as on most plans. The deductible is used up line by line.
5. Multiply by the coverage percentage for the line's category: preventive, basic or major.
6. Cap at the yearly maximum left. Once the maximum runs out, insurance pays nothing more on later lines.
7. The patient owes the rest. In network that's the contracted fee minus insurance. Out of network it's your fee minus insurance, so it includes the gap above the plan's fee.

The formula for one line

Insurance = (allowed fee, after any downgrade, minus the deductible left) × the coverage percentage, but no more than the yearly maximum left.

Patient portion = the fee you bill minus insurance. In network you bill the contracted fee; out of network, your own fee.

Work the lines in order, because the deductible and the yearly maximum get used up as you go.

A worked example

In network. Coverage is 100% preventive, 80% basic, 50% major. $50 of the deductible is left and $1,000 of the yearly maximum.

Insurance used $706 of the $1,000 maximum, so nothing was capped. With $500 left instead, the crown's insurance would stop at $344 and the patient would owe $756 on it.