• Write-offs:

  • Automatically post contracted write-offs when claims are created - Calculate the write-off; post the write-off automatically when a claim is created.

  • Manually post contracted write-off during claim adjudication - Calculate the write-off; do not post the write-off automatically when a claim is created.

  • No write-off. Post contracted fee, if applicable - Do not calculate the write-off.

• Enable Payment Tables - Override the coverage percentage if the posted/charted procedure exists in the plan's payment table.

• PPO Write-offs or Contracted Amounts - Use the Billing Provider or Rendering Provider.

• Billing Provider:

  • Specific Provider - Specify the primary provider or the location.

  • Provider of Procedures - Specify the primary or secondary provider.

    • To handle cases where the provider of procedure is not an active Primary Provider, select an alternate Billing Provider - Specify the primary provider or the location.

• Rendering Provider:

  • Specific Provider - Specify the primary provider.

  • Provider of Procedures - Specify the primary or secondary provider.

    • Use the patient's primary provider if the provider of procedures is not an active Primary Provider:

      • With checkbox clear, for To handle cases where the provider of procedures is not an active Primary Provider, select an alternate Rendering Provider, specify the primary provider.

      • With checkbox selected, for To handle cases where the patient has no Primary Provider or provider of procedures is not an active Primary Provider, select an alternate Rendering Provider, specify the primary provider.

• Code - The code is relevant for coverage tables, payment tables, fee schedules, and when the procedure is posted/charted.

• Location Fee - The fee in the location's preferred fee schedule. (The fee can vary by location.)

• Bill to insurance - This switch determines the default state of the switch when the procedure is posted/charted. (This is an organization-level setting.)

• Preferred fee schedule - The location's preferred fee schedule is used for PPO write-offs or contracted amounts if the location is the billing/rendering provider according to the insurance defaults.

• Use this location as a claim provider for insurance:

  • Claim Provider tab > Contracted with - The carriers that the location is contracted with. This is relevant if the location is the billing/rendering provider according to the insurance defaults.

  • Claim Provider tab > Post UCR for Maxed Patients - The carriers that allow you to charge your UCR fee when the patient's annual maximum benefit has been reached.

• Fee Schedule - The provider's assigned fee schedule is used for PPO write-offs or contracted amounts if the provider is the billing/rendering provider according to insurance defaults.

• Contracted with - The carriers that the provider is contracted with. This is relevant if the provider is the billing/rendering provider according to the insurance defaults.

• Paid in Full Enabled - If this is selected, a Paid in Full column is available.

• Current Fee - The amount to charge.

• No Write-off - An automatic write-off will be posted for the procedure unless this fee schedule is the plan's contracted fee schedule. (This option is available only if not posting contracted fees; and can be selected only if Paid in Full is not selected.)

• Paid in Full (available only if Paid in Full Enabled is selected; and can be selected only if No Write-off is not selected) - Instead of the patient being responsible for a portion of the charge, anything over the maximum allowed (contracted) rate gets written off.

• Post UCR Fee - The UCR fee will be posted instead of the contracted (max allowed) fee. (This option is available only if posting contracted fees.)

• Max allowable amount fee schedule - The fee schedule for determining contracted (max allowed) amounts.

• Max Allowable Amount Fee Schedules By Location - The contracted fee schedules can be set per location.

• Coverage Table:

  • By coverage percentage:

    • Code Range.

    • Deductible Type.

    • Coverage %.

    • Exception - Not covered, frequency, shared frequency, downgrade, or age limitation. (Currently, waiting period is ignored for automatic insurance calculations.)

  • By patient copayment:

    • Code.

    • Deductible Type.

    • Copayment $.

    • Exception - Currently, exceptions are ignored for automatic insurance calculations.

• Benefits:

  • Deductibles:

    • Annual Individual Required - Preventive, Basic, Major, or Ortho.

    • Annual Family Required - Preventive, Basic, or Major.

    • Lifetime Individual Required - Preventive, Basic, or Major.

  • Benefits:

    • Annual Individual Maximum.

    • Annual Family Maximum.

    • Lifetime Ortho Maximum.

• Payment Table:

  • Code.

  • Amount.

• Source of payment - The type of insurance company (such as commercial or Medicaid).

• Coordination of Benefits:

  • Source of Payment for Primary Insurance Plan - The type of primary insurance company.

  • Method for Coordination of Benefits - The method for handling the Coordination of Benefits (COB) between the primary and secondary insurance claims: Traditional, Maintenance of benefits, or Carve Out/Non Duplication.

• Location - The place of service depends on the location that was logged in to when the procedure was posted/charted. The location is relevant for knowing which location's insurance defaults to use. Also, the location can affect which location's preferred fee schedule to use.

• Transaction date - The date of service must be within plan's coverage period. Also, the date is relevant if a frequency coverage exception applies.

• Provider - The provider can affect the amount being charged.

• Procedure - The procedure is relevant for the coverage table, payment table, and fee schedule. Also, the procedure can be downgraded to another procedure if a downgrade coverage exception applies.

• Bill to insurance - This switch determines whether the procedure should be billed to insurance or not. (The default state of this switch can be changed for this procedure code (an organization-level setting).

• Amount:

  • If not posting contracted fees using rendering/billing provider - The amount comes from the provider's fee schedule if one is assigned; otherwise, the amount comes from the location's preferred fee schedule.

  • If posting contracted fees using rendering/billing provider - If the rendering/billing provider according to insurance defaults is contracted with the carrier, the amount comes from plan's max allowed fee; otherwise, the amount comes from the location's preferred fee schedule. The amount may need to be updated (if it does not match the applicable fee schedule).

• UCR fee - The amount comes from the provider's fee schedule if one is assigned; otherwise, the amount comes from the location's preferred fee schedule. This amount is billed to insurance on claims. (This option is available only if posting contracted fees using rendering/billing provider.)

• Tooth, Surfaces, etc. - The treatment area is relevant if a frequency coverage exception applies.

• Insurance Estimates tab:

  • Outstanding Insurance Estimates:

    • Automatically calculate insurance estimates - If this switch is off, make sure that the estimates are correct, or turn the switch on to have the estimates calculated automatically.

    • Prim. ins portion - The estimated primary insurance portion.

    • Sec. ins portion - The estimated secondary insurance portion (if the patient has secondary coverage).

    • Ins write-off - The estimated write-off.

    • Guar. Portion - The estimated guarantor portion.

  • Insurance Estimates Overrides:

    • Primary - The amount to use for the primary insurance's portion.

    • Secondary - The amount to use for the secondary insurance's portion (if the patient has secondary coverage).

• Birth date - The patient's birth date is relevant if an age limitation coverage exception applies.

• Primary provider - The provider is relevant if needed to determine the rendering provider (for PPO write-offs or contracted amounts).

• None.

• Basic (uninsured):

  • Select a fee schedule.

  • Discount plan expiration.

• Sliding fees:

  • Patient pays per visit.

• Order - Primary, secondary, or so forth.

• Coverage Period - The date of service must be within the plan's coverage period.

• Coverage table.

• Benefits:

  • Deductibles:

    • Annual Individual Met - Preventive, Basic, Major, or Ortho.

    • Annual Family Met - Preventive, Basic, or Major.

    • Lifetime Individual Met - Preventive, Basic, or Major.

  • Benefits:

    • Annual Individual Used.

    • Annual Family Used.

    • Lifetime Ortho Used.

    • Annual Individual Implant - Maximum (read only) or Used.

    • Lifetime Individual Implant - Maximum (read only) or Used.

Understanding how insurance estimates are calculated

Dentrix Ascend calculates insurance portions, write-off adjustments, and patient portions automatically. The explanation that follows covers estimates for primary and secondary plans. The same rules and calculations that apply to secondary plans apply to plans for other coverage orders (tertiary, quaternary, and so forth); however, the calculations are not performed automatically.

The commercial insurance plans that Dentrix Ascend supports are PPO (Preferred Provider Organization), DHMO (Dental Health Maintenance Organization), and indemnity.

Notes:

• Before calculating insurance estimates for procedures posted on the current date, Dentrix Ascend takes into account any pending primary and secondary claims (in the order they were sent, and claims with the highest total billed amount being handled first) for the patient, the subscriber of the patient's plan (if not the same person), and any other dependents on the plan. However, insurance estimates do not take into account a tertiary plan unless a claim for that plan is attached to a secondary claim; likewise, estimates do not take into account a quaternary plan unless a claim for that plan is attached to a tertiary claim; and so forth.

• Dentrix Ascend processes procedures being billed to insurance chronologically (oldest to newest, by procedure dates), by descending procedure predetermination or override amounts (largest to smallest), and then by descending procedure amounts (largest to smallest).

• When calculating estimates for an insurance payment, Dentrix Ascend processes only the procedures associated with the current claim. The maximums and deductibles are calculated as if the current claim is the next one to be paid.

• For Dentrix Ascend to calculate estimates for procedures posted on the current date, the patient must have an active primary insurance plan with coverage dates that include the dates of those posted procedures.

• In a patient's ledger, estimates can include procedures posted on the current date (whether or not those procedures are attached to a claim) and procedures posted on prior dates (only if those procedures are attached to a claim). In a patient's treatment plan, estimates can include procedures regardless of when were planned (on the current date or on prior dates) even if they are not attached to a predetermination.

• The deductible type for multiple procedures posted on the same date is determined by the first procedure.

• The billing provider, which is determined by the insurance defaults, may be different from the provider who is associated with a procedure.

• Patient payments and credit adjustments that are applied to procedures reduce the estimated patient portion. Insurance payments that are less than what is expected to be paid reduce the estimated insurance portion and increase the estimated patient portion. Partial insurance payments (more is expected to be paid) reduce the estimated insurance portion.

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For additional help with understanding fees (where they come from and how they figure into insurance estimates) and insurance estimates (including a more detailed look at how they are calculated), refer to the following information.

Who this is information for: Anyone in your office who has ever stared at a procedure's estimate and asked, "Where did that number come from?"—front desk, treatment coordinators, billing staff, office managers, and anyone training new hires.

The big idea: When you post or chart a procedure, Dentrix Ascend has to fill in four numbers:

• Charge - How much does this procedure cost?

• Insurance Portion - How much will insurance pay?

• Write-off - How much do we "eat" because of our contract with the carrier?

• Patient Portion - How much does the patient owe?

These four numbers always have to add up to the same thing:

• Charge = Insurance Portion + Write-off + Patient Portion

Everything explained here is how Dentrix Ascend fills in those four boxes.

Glossary

Word	What it really means
UCR	Your office's normal price. Stands for Usual, Customary, Reasonable. Think of it like the sticker price on a car.
Allowed Amount / Contracted Fee / Max Allowable	The price the insurance company has agreed to honor under your contract. Think of it like the negotiated price—almost always lower than UCR.
MAF (Max Allowable Fee Schedule)	The list of contracted fees the carrier gave you, code by code.
Write-off	UCR minus Allowed. The discount you agreed to eat by signing the contract.
Insurance Portion	What insurance is expected to pay.
Patient Portion	What the patient (the guarantor) is expected to pay.
Deductible	What the patient has to pay before insurance starts paying. Think of it like the deductible on car insurance.
Benefits / Maximum	The cap on what insurance will pay this year (or lifetime, for ortho). Once you hit it, insurance stops paying.
Coverage %	The percentage insurance covers after the deductible. 80% / 60% / 50% are typical.
Coverage Table	The plan's list of which procedures are covered and at what %.
Payment Table	A list of fixed dollar amounts insurance will pay for specific procedures (overrides the %).
Coordination of Benefits (COB)	The rules for how primary and secondary insurance work together.
Maxed Out	The patient has used up all of their annual or lifetime benefit.

1. The Three Office Modes (Pick One)

Every office picks one way to handle write-offs at the organization level. This is the single biggest decision affecting estimates, because it changes what number actually shows up on the procedure in the ledger.

Mode A - Auto-post the write-off

• The procedure shows UCR as the price.

• The write-off is calculated and posted automatically when the claim is created.

Think of it as: "List the full price, then subtract the discount automatically when we mail the bill."

Mode B - Manual write-off (post during adjudication)

• The procedure shows UCR as the price.

• The write-off is calculated, but it doesn't actually post until your billing person applies it during EOB/ERA adjudication.

Think of it as: "List the full price. Wait for the insurance check, then write off the discount when we reconcile."

Mode C - No write-off / Post Contracted Fee (a.k.a. Post Max Allowable / Post Primary Max Allowable)

• The procedure shows the contracted fee as the price (no separate write-off line on the ledger).

• The UCR is still billed on the claim. The carrier still sees your normal price for their records. Dentrix Ascend just keeps it in a separate "UCR fee" field on the procedure instead of posting a write-off entry.

Think of it as: "Skip the ‘list price minus discount' dance on the ledger. Post the discounted price directly. The carrier still sees our regular price on the claim."

A simple comparison:

Mode	Procedure shows	UCR billed on the claim?	Contracted fee on the claim?	Write-off on the ledger?
A - Auto write-off	UCR	Yes	Yes (the "Allowed Amount")	Yes (auto when claim is created)
B - Manual write-off	UCR	Yes	Yes (the "Allowed Amount")	Yes (when staff adjudicates the EOB)
C - Post Max Allowable	Contracted fee	Yes (kept in a separate UCR fee field)	Yes (it's the same as the procedure amount in this mode)	No

Heads up: Mode C requires both the organization setting and a feature enabled. Without the feature enabled, picking "No write-off" in the menu won't actually swap the procedure amount.

2. The Big Picture Formula

Every estimate is just these steps, in order:

1. Figure out the Charge (UCR in Modes A and B; the contracted fee in Mode C).

2. Figure out what insurance will pay (the Insurance Portion).

3. Figure out the Write-off (UCR minus Allowed, when you're contracted; otherwise zero).

4. Whatever's left is the Patient Portion.

Steps 1 and 3 are basically lookups. Step 2 is the complicated one—it walks through the following:

• Did anyone enter a manual override?

• Is the procedure in the payment table (fixed dollar amount)?

• Is the procedure in the coverage table (percentage)?

• Are there any special rules (not covered, frequency limits, downgrades, age limits)?

• Has the patient met their deductible?

• Does the patient have any benefits left?

• Is there a secondary insurance? How does it coordinate?

We'll walk through each of those.

3. Where Does the Procedure Charge Come From?

Dentrix Ascend looks for the price in this order:

1. Does the provider have their own fee schedule? Use that.

2. If not, does the location have a preferred fee schedule? Use that.

3. If neither, the price is 0.

A few exceptions:

• If the patient is on the sliding fee program (uninsured, low income), the price gets adjusted down using the office's sliding fee table.

• If the patient has a discount plan (and no insurance), use the discount plan's fee schedule.

• If your office is in Mode C, and the rendering/billing provider is contracted with the carrier, and the carrier has a Max Allowable Fee Schedule, the procedure amount becomes the contracted fee instead of UCR.

4. Two Special Numbers: UCR and Allowed Amount

For every estimate involving insurance, Dentrix Ascend keeps track of two numbers:

• UCR - your office's normal price for this procedure.

• Allowed Amount - what your contract with the carrier says you're allowed to charge for it (looked up on the MAF).

The difference between them is the Write-off:

• Write-off = UCR - Allowed Amount (only if your provider is contracted with the carrier; otherwise zero)

The Allowed Amount also affects the math itself:

• If Allowed < UCR - Insurance bases its % on the Allowed amount. There's a write-off.

• If Allowed ≥ UCR - Insurance bases its % on the UCR (the smaller of the two). No write-off.

• If your provider isn't contracted with the carrier - No write-off. The patient owes whatever insurance doesn't pay.

• If the carrier doesn't have a MAF on file - No Allowed Amount. No write-off.

Important: Mode C still bills UCR on the claim

In Mode C, the procedure on the ledger uses the contracted fee directly, so there's no separate write-off line. But the claim still shows UCR as the billed amount. Carriers expect to see your normal price for their records. Dentrix Ascend tracks the UCR in a separate "UCR fee" field on the procedure when the office is in Mode C, and that's what gets sent on the claim.

In other words:

• What posts to the ledger changes between modes.

• What the carrier sees on the claim doesn't—UCR is always submitted.

Post UCR for Maxed Patients

A newer setting lets you say, "For these specific carriers and providers, when the patient runs out of insurance benefits, switch the procedure amount back to UCR (instead of the contracted fee)."

This kicks in when all of these are true:

• The feature is turned on for your org.

• The patient's primary insurance is maxed out (annual individual or annual family benefit fully used).

• If the patient has a secondary, it has to be maxed out too.

• The provider x insurance carrier combination is in the Post UCR for Maxed Patients list.

  Note: For patients with a secondary, both the primary and the secondary carrier x provider have to be in the list.

When all of those line up:

• The procedure amount switches to UCR.

• The write-off adjustment is cleared.

• The carrier still won't pay anything, because the patient has no benefits left, so the patient ends up owing UCR.

If any one condition isn't met (most commonly: the carrier isn't in the list), Dentrix Ascend keeps using the contracted fee even though the patient is maxed. Insurance still pays $0, so the patient owes the contracted amount.

Why would a practice opt in? Some carriers want to see UCR (instead of the negotiated rate) on the claim once the patient is maxed, sometimes for tracking, sometimes for audit. The opt-in lets you give those carriers what they want, carrier by carrier.

5. "Outstanding Insurance Estimates": On or Off

Each procedure has a switch called Outstanding Insurance Estimates.

• ON (auto-calculate) - Dentrix Ascend does all the math automatically using the steps in this guide.

• OFF (manual) - You type the four numbers yourself: Primary Ins. Portion, Secondary Ins. Portion, Ins Write-off, and Patient Portion. Dentrix Ascend just makes sure they add up. Everything else is ignored—overrides, payment table, coverage table, exceptions, deductibles, benefits.

Most procedures stay on auto-calc. Manual is mainly used for unusual situations.

6. The 7 Steps Ascend Runs (When Auto-Calc Is On)

For every procedure that has insurance, Dentrix Ascend runs these steps in order. Steps 1 and 2 can short-circuit the rest.

Step 1 - Did the user enter a manual override?

• If yes - The override is the Insurance Portion. Skip everything else (payment table, coverage table, deductible, benefits).

• The override can never exceed the Charge.

• The Write-off still depends on whether you're contracted with the carrier and whether there's an MAF.

Step 2 - Is the procedure in the Payment Table?

• The payment table is a list of fixed dollar amounts insurance will pay for certain procedures.

• If yes (and the plan uses a percentage coverage table) - Use the payment table amount instead of doing percentage math.

• If no - Move on to the coverage table.

• For copay plans (DHMO) - The payment table is ignored entirely. Copay always wins.

Step 3 - Look up the procedure in the Coverage Table

The coverage table tells you:

• The coverage % (example: 80% for preventive, 60% for basic, 50% for major).

• The deductible type (Preventive, Basic, Major, Ortho, or None).

• Any special rules (exceptions) - see Section 7.

If the procedure isn't in the coverage table at all, insurance pays nothing. The patient owes the Allowed Amount (or the full UCR if you're not contracted).

Step 4 - Subtract the Remaining Deductible

• If the patient still owes 50 toward their deductible, the first 50 of the basis amount goes toward that. Insurance starts paying after that.

Step 5 - Apply the Coverage % (or payment table cap)

• If the payment table does not apply - Insurance Portion = (Basis after deductible) × Coverage %.

• If the payment table applies - Insurance Portion = the smaller of the % calculation and the payment table dollar amount.

Step 6 - Cap by Remaining Benefits

• Insurance can never pay more than the patient has left in their annual maximum (or lifetime maximum, for ortho).

• If the patient has 200 left and the math says insurance owes 300, it gets capped at 200.

Step 7 - The Patient Owes Whatever's Left

• PPO formulas:

  • Patient = min(Charge, Contracted Fee) - Insurance Portion - Write-off

• Indemnity formula (no contract / no write-off):

  • Patient = Charge - Insurance Portion

That's it. Now let's drill into the trickier bits.

7. Special Rules (Coverage Exceptions)

A coverage row can have a special rule attached. Ascend applies them in priority order - only one wins per procedure. From highest priority (applied first) to lowest:

1. Not Covered

2. Waiting Period (display only—calculate as if no exception)

3. Frequency Limit

4. Age Limit

5. Downgrade

Not Covered

Insurance pays 0. The patient owes the Allowed Amount (or full UCR if no MAF / not contracted). No write-off if not contracted.

Frequency Limit

"Once every 6 months" or "Twice a year."

• For procedures with a tooth/surface (like D2140 fillings):

  • Same procedure on the same tooth+surface within the limit → treat like Not Covered.

  • Same procedure on a different tooth+surface → calculate as normal.

• For procedures without a tooth (like D0140 exams):

  • Within the limit → calculate as normal.

  • Beyond the limit → treat like Not Covered.

Downgrade

"We'll cover the cheaper version." For example, the carrier covers D0140 (problem-focused exam) at the price of D0120 (periodic exam).

Two key points:

• The Insurance Portion uses the downgrade procedure's Allowed amount and coverage %.

• The Insurance Portion can never be more than what the original procedure would have paid normally—if the downgrade math comes out higher than the original, fall back to the original calculation.

• The deductible still uses the original procedure's deductible type (not the downgrade's).

Age Limit

"Sealants only covered for kids 6-14."

• Patient is outside the age range - Calculate as normal (the row keeps its regular coverage rate).

• Patient is inside the age range - Apply the exception:

  • Either an alternate coverage % (for example, covered at 80% instead of 100%).

  • Or a downgrade procedure (treat it like a downgrade for this patient).

Waiting Period

A flag for your information. Doesn't change the math.

8. Copay (DHMO) Plans

Some plans use patient copays instead of percentages. Each procedure has a fixed dollar amount the patient pays; insurance covers the rest, up to the Allowed Amount.

The same provider-contracted vs. not-contracted, MAF vs. no-MAF logic applies. The basic idea:

• The patient pays the smaller of the copay or the procedure charge.

• Insurance pays whatever's left, up to the Allowed Amount (when there's a MAF and the provider is contracted).

• The exceptions (frequency, age limit, downgrade) and the payment table are ignored for copay plans—the copay table is the rule.

9. Insurance Estimate Overrides

Each procedure has two override fields: Primary and Secondary.

If you type a value in:

• That value becomes the Insurance Portion for that plan.

• All the math is skipped—no payment table, no coverage table, no deductible, no benefits cap.

• The override can't be more than the procedure Charge.

• Write-off is still calculated based on whether the provider is contracted with the carrier and whether there's a MAF.

10. Deductibles, Explained

Deductibles work in three buckets:

1. Annual Individual Deductible - What this patient owes before insurance pays, this year.

2. Annual Family Deductible - What the whole family owes before insurance pays, this year.

3. Lifetime Individual Deductible - What this patient owes once, ever.

Each bucket can also be split by deductible type (Preventive, Basic, Major, Ortho).

The rule: Take the smallest binding amount.

• If any bucket is already met, the deductible required is 0.

• Otherwise, take the smallest of the remaining amounts.

For ortho, only the Lifetime Ortho deductible matters.

A required deductible of 0 or empty = no deductible needed.
A required deductible > 0 with less met = deductible still applies.

Each procedure consumes part of the deductible as it goes. So if you're estimating three procedures in a row, the second and third see the deductible getting "used up" by the first.

11. Benefits, Explained

Benefits work just like deductibles—three buckets:

1. Annual Individual Maximum - Most insurance will pay for this patient this year.

2. Annual Family Maximum - Most insurance will pay for the whole family this year.

3. Lifetime Ortho Maximum - Most insurance will pay for ortho, ever.

The rule: Take the smallest binding amount.

Some plans also track Annual / Lifetime Implant maximums separately. They show in the UI but currently don't cap the insurance estimate the way the annual maximums do - treat them as informational for now.

A maximum of 0 or empty = no benefit, insurance pays 0.

A maximum > 0 that's fully used = the patient is maxed out for the year.

12. Secondary Insurance and Coordination of Benefits

When a patient has two plans, the secondary plan handles the leftover differently depending on its COB Method:

Method	What it does
Traditional	Secondary calculates as if it were the only plan. No reduction for what primary paid. This is the default if no COB rule matches.
Maintenance of Benefits (MOB)	Secondary's basis amount is reduced by what primary paid (or estimated to pay) before applying secondary's coverage %.
Carve Out / Non-duplication	Same reduction, but applied after secondary's coverage %. The carrier never pays more than its own share minus what primary already paid.

The Write-off ends up as the larger of the two plans' write-offs (whichever protects the patient more).

What is "Source of Payment"? Each plan has a Source of Payment (Commercial, Medicaid, Discount, etc.). The COB row on the secondary plan tells the system "if the primary's source of payment is X, use this COB method."

13. Special Per-Line Flags on Fee Schedules

A fee schedule can mark individual procedure codes with:

Flag	What it does
Paid in Full	"If insurance pays this, we eat the rest." Patient owes 0; the whole remaining balance becomes a write-off.
No Write-off	"Don't write off the difference." Even if the contracted fee is less than UCR, no write-off is generated. The patient owes UCR.
Post UCR Fee	"For this code, ignore Mode C and post UCR like Mode A." Lets you mix and match modes per code.

14. Examples

Setup for all examples:

• UCR = 234

• Allowed (MAF) = 217

• Coverage % = 60%

• Annual Individual benefit remaining = 800

• Annual Family benefit remaining = 1,200

• Annual Individual Basic deductible remaining = 25

• Procedure is in the coverage table with deductible type Basic

• No payment table entry, no override, no exception

Example 1 - Mode A (Auto write-off), contracted, has a MAF

Step 1: No override.

Step 2: Not in payment table.

Step 3: Coverage table says 60% for Basic deductible type.

Step 4: Apply $25 deductible. Basis = $217 − $25 = $192.

Step 5: Insurance = $192 x 60% = $115.20.

Step 6: Plenty of benefits left ($800), no cap.

Step 7: Write-off = $234 − $217 = $17.

Patient = $217 − $115.20 − $17 = $84.80.

Procedure shows: Charge 234, Insurance 115.20, Write-off 17, Patient 84.80.

Example 2 - Same scenario, Mode C (Post Max Allowable)

Procedure amount becomes the Allowed = $217.

The claim still shows UCR ($234) as the billed amount.

Step 4: Apply $25 deductible. Basis = $217 − $25 = $192.

Step 5: Insurance = $192 x 60% = $115.20.

Step 7: Patient = $217 - $115.20 = $101.80.

Procedure shows: Charge 217, Insurance 115.20, Write-off 0 (built into the price), Patient 101.80.

Claim shows: UCR 234 as the billed amount; 217 as the Allowed/contracted fee.

Example 3 - Patient is maxed out, certain feature is enabled, carrier opted in (Mode C)

Patient has used 100% of their annual individual benefit.

The carrier x provider IS in the Post UCR for Maxed Patients list.

Procedure amount switches from $217 (Allowed) to $234 (UCR).

Write-off adjustment is cleared.

Step 6: Remaining benefit = 0, so Insurance = $0.

Step 7: Patient = $234.

Procedure shows: Charge 234, Insurance 0, Write-off 0, Patient 234.

Claim shows: UCR 234 (no contracted fee, since we're intentionally bypassing it).

If the carrier weren't opted in, the procedure would stay at 217 with Patient 217 (insurance still pays 0 because the patient is maxed).

Example 4 - Override of 200 entered as Primary, no MAF

Step 1: Override = $200, so Insurance = $200. Skip the rest.

Write-off = $0 (no MAF in this scenario).

Patient = $234 − $200 = $34.

Procedure shows: Charge 234, Insurance 200, Write-off 0, Patient 34.

Example 5 - Downgrade D0140 to D0120

D0140 (original): UCR 234, Allowed 217, Coverage 60%, deductible already met.

D0120 (downgrade): UCR 120, Allowed 100, Coverage 60%.

Step 3: Downgrade applies.

Insurance = $100 x 60% = $60 (using downgrade's numbers).

Cap check: $60 isn't above what the original would have paid ($217 x 60% = $130.20).

Keep $60.

Step 7: Write-off = $234 − $217 = $17.

Patient = $217 - $60 = $157.

Procedure shows: Charge 234, Insurance 60, Write-off 17, Patient 157.

Example 6 - Secondary insurance with Maintenance of Benefits

Same primary as Example 1 (Insurance 115.20, Write-off 17). Secondary plan: 60% coverage, no MAF, COB = MOB.

The big idea: the secondary's basis gets reduced by what the primary paid before the secondary applies its 60%. So instead of the secondary calculating as if it were the only plan and possibly paying another 140, it just "tops off" what primary couldn't cover.

The Patient Portion ends up smaller than it would have been with primary alone, because secondary chips in some of what primary didn't cover.

Quick Reference Tables

Standard formula by setup

Has MAF?	Provider contracted?	Insurance Portion	Write-off	Patient
Yes	Yes, Allowed < UCR	Allowed x Coverage %	UCR - Allowed	Allowed - Insurance
Yes	Yes, Allowed ≥ UCR	UCR x Coverage %	0	UCR - Insurance
Yes	No	Allowed x Coverage % (or UCR x %, whichever is smaller)	0	UCR - Insurance
No	n/a	UCR x Coverage %	0	UCR - Insurance

What posts where, by mode

	Mode A (Auto)	Mode B (Manual)	Mode C (Post Max Allowable)
Procedure amount on the ledger	UCR	UCR	Contracted fee
Write-off line on the ledger	Auto when claim is created	When billing person adjudicates	None
UCR sent on the claim	Yes	Yes	Yes (separate UCR fee field)
Contracted fee sent on the claim	Yes	Yes	Yes (it's the same as the procedure amount)

Where to find each setting

Setting	Where it lives
Auto / Manual / No write-off mode	Settings > Ledger Options > Write-off option
Enable Payment Tables	Settings > Ledger Options
Insurance defaults (billing vs rendering provider)	Settings > Insurance Defaults (per location)
Provider's contracted carriers	Provider profile > Contracted with
Per-line Paid in Full / No Write-off / Post UCR Fee	Fee Schedules > schedule item
Max Allowable Fee Schedule (MAF)	Carrier Plan > Max allowable amount fee schedule
Coverage Table / Payment Table / Benefits / Deductibles / COB	Carrier Plan
Insurance Estimate Overrides (Primary / Secondary)	Procedure > Insurance Estimates tab
Outstanding Insurance Estimates (on/off)	Procedure > Insurance Estimates tab
Post UCR for Maxed Patients (per provider × carrier)	Insurance Carriers > Post UCR for Maxed Patients

Cheat-Sheet Glossary (the very short version)

• UCR - Your normal price.

• Allowed Amount / Contracted Fee / Max Allowable - What your contract says you can charge.

• MAF - The spreadsheet of contracted fees.

• Write-off - UCR minus Allowed (the discount you eat).

• Insurance Portion - What insurance is expected to pay.

• Patient Portion - What the patient owes.

• Deductible - What the patient pays before insurance starts paying.

• Benefits / Maximum - The cap on what insurance pays this year.

• Coverage % - The percentage insurance pays after the deductible.

• Payment Table - Fixed dollar amounts that override the %.

• COB - The rules for combining primary and secondary insurance.

• Maxed Out - The patient has used up all their annual or lifetime benefit.

• Mode C / Post Max Allowable / Post Primary Max Allowable - Post the contracted fee directly on the procedure (UCR is still billed on the claim).