Fee Schedule Logic

The Fee Schedule used for procedure fee estimates is determined using the logic below.

If the procedure code is a dental code (without a medical code) the logic is as follows:

  1. If the patient has insurance, the fee schedule of the first insurance plan listed in the Family module is used (e.g. order = 1 on the Insurance Plan).
  2. If a fee schedule is set for the patient in the Edit Patient Information, this fee schedule is used (rare).
  3. If there is no insurance plan or patient fee schedule, the fee schedule of the provider who has priority is used.
    • Priority 1: The provider assigned to the procedure, if any (Assign to Prov on the Procedure Code).
    • Priority 2: The provider assigned to the procedure's appointment or to any appointment scheduled today.
    • Priority 3: The patient's primary provider.

If the fee schedule has provider and/or clinic specific fees, Open Dental will use clinic/provider fee first, then provider-only fee, then clinic only fee. Thus a provider-only fee trumps a clinic-only fee, but both are trumped by a clinic and provider fee. See Providerand/or Clinic-Specific Procedure Fees.

Example: The procedure has provider fee of $100, a clinic fee of $150, and a clinic/provider fee of $175. Open Dental will use the $175 fee.

If a procedure code has a medical code, the logic is as follows:

  1. If the patient has medical insurance, the fee schedule of the first medical insurance plan listed in the Family module is used. If the code is a dental code cross-coded to a medical code, the setting in Chart Module Preferences for Use medical fee for new procedures determines the fee. If checked the fee of the medical code is used; if unchecked the fee of the dental code is used.
  2. If there is no medical insurance, the fee schedule of the first insurance plan listed in the Family module is used (e.g. order = 1 on the Edit Insurance Plan).
  3. If a fee schedule is set for the patient in the Edit Patient Information window, this fee schedule is used (rare).
  4. If there is no insurance plan or patient fee schedule, the fee schedule of the provider who has priority is used.

    Priority 1: The provider assigned to the procedure, if any (Assign to Prov on the Edit Procedure Code window).

    Priority 2: The provider assigned to the procedure's appointment or to any appointment scheduled today.

    Priority 3: The patient's primary provider.

Note: For PPO insurance plans that have two fee schedules (PPO fee schedule and Provider fee schedule), the procedure fee is based on the fee schedule that has the higher fee.