Calculating Co-Payment

Copayment Calculation

You will need 3 things to calculate your copay:

  1. Procedure code: Dentist can give you or you can find out.
  2. Procedure code cost: Insurance can tell you
  3. Breakdown of benefits: your insurance coverage that tells you what percentage is your treatment cost or procedure code covered.
    • optional: calculator

Few terms that you should know before you calculate to identify the information you need.

Standard fee schedule OR Fees OR Charges = Dentist office fees/cost that you are charged if you dont have any insurance.

Contracted fees/allowance OR Insurance fees OR MPA (Maximum plan allowance = Insurance contracted fees with the particular dental office (varies from office to office)

Coverage of Benefits (breakdown of benefits) = defines the contribution of individual and insurance

For example: if fillings are covered at 80% it means insurance will pay 80% and patient pays 20% of the contracted fees.

Deductible = any amount that the individual has to pay before any insurance payments.

Explanation of benefits: once claim is process and payment is sent with explanation that how much insurance covered and how much is the individual’s responsibility.

IN SHORT FORM

Procedure code for crown Office fees Insurance negotiated fees Insurance coverage Insurance payment portion Patient payment portion Loss to Dentist
D2750 1000 900 50% 450 450 100

your payment portion will increase if you have to pay the deductible, or insurance downgrades or denies the payment for your service but the maximum amount you will end up paying will be $900.