Thursday, March 19, 2015

What fee should I bill on the claim?

The topic of full fee vs. PPO fee and how to bill it all to the insurance companies has been a heated point of discussion during the three years I have been writing the blog. Insurance companies are constantly setting their own rules about the claim format and dental offices are trying to keep up with all of the changes in the claim formats.

In Dentrix version G5.2, the development team made some significant feature improvements to help you alter the claim format for individual insurance companies if needed. This new feature enhancement can also give you more flexibility when billing out fees for a specialist or for a provider who is not contracted with a PPO plan.

If you go to the Office Manager > Maintenance > Reference > Insurance Maintenance then open up the Insurance Data box, you will find a radio button to the right of the Claim Format. Click on the Claim Format button to open the options available. You will notice many choices … but the one I am most excited about is the drop down menu under Provider and Fee Options. If you click on the drop down menu under fee schedule, then you can choose for this insurance plan if you want bill out the Default fee schedule, Billing Provider fee schedule, or Insurance fee schedule. Here are the definitions:
  • Default – This will bill out whatever fees are posted to the patient’s ledger.
  • Billing Provider – Whichever provider is used as the Billing Provider on the claim will have his or her fee schedule pulled. This is similar to using the “F” claim forms. However, many of you may be under the impression that it pulls the patient’s PROV1. If you go to the provider setup, each provider has a fee schedule attached to his or her profile. This feature could be extremely helpful if you have a specialist who comes into your office and you want to bill out a higher fee than the office’s regular fees. For example, if you have an endodontist come in once a week and you bill out a molar root canal for a patient, you could open up the insurance claim and change the billing provider to the endodontist so that his or her fee goes out on the insurance claim.
  • Insurance Plan – This will bill out the insurance plan fee schedule if you have one attached to the insurance plan info screen. If you have used any of the “I” claim forms in the past, this feature will perform similar to that.

These new Claim Format features are available with G5.2 and the DX2007 and DX2012 claim forms. Check out the other features within the Claim Format button and see if any of these will pertain to your insurance plans.

Dayna Johnson, Certified Dentrix Trainer
Dayna loves her work. She has over 25 years of experience in the dental industry, and she’s passionate about building efficient, consistent, and secure practice management systems. Dayna knows that your entire day revolves around your practice management software—the better you learn to use it, the more productive and stress-free your office will be. In 2016, Dayna founded Novonee ™, The Premier Dentrix Community, to help cultivate Dentrix super-users all over the country. Learn more from Dayna at and contact Dayna at

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