Category Percentage Insurance Plan

Set up an out-of-network Insurance Plan Type when the office is not contractually obligated to reduce its fees. This is a traditional percentage insurance plan.

Out-of-Network Plan Using Blue Book

Blue Book is a a tool that uses allowed fees entered on received claims to update estimates for future procedures. See Insurance Blue Book Setup.

  1. Optional: create a Manual Blue Book Fee Schedule for the carrier's known fees.
  2. On the Insurance Plan:
    • Plan Type: Category Percentage
    • Fee Schedule: None
    • Manual Blue Book: The carrier's out-of-network fee schedule (optional)
    • Use Blue Book: Ensure this box is checked to use Blue Book for insurance estimates.

When Blue Book is enabled, Manual Blue Book is the only Carrier Allowed Amount fee schedule available. Manual Blue Book fees may or may not be selected based on the hierarchy set up in Insurance Blue Book Setup.

Out-of-Network Plan with a Fee Schedule

Even if the office is not contractually obliged to follow out-of-network fees, offices can enter the fees in order to get more accurate insurance estimates..

  1. Create an out-of-network Fee Schedule for the carrier and enter the out-of-network fees.
  2. On the Edit Insurance Plan window, set the following:
    • Plan Type: Category Percentage
    • Fee Schedule: None (uses the provider's default fee schedule, e.g., office fees)
    • Out of Network (Old): The carrier's out-of-network fee schedule

All fees on procedures will show the provider's fees, but the out-of-network fee schedule will be used for estimates. Percentages will be based on the out-of-network fee schedule. The patient is still responsible for any difference between the office fee and the published insurance fee. If desired, the office can update out-of-network fees as users enter claims and payments.

Out-of-Network Plan with No Fee Schedule

In this setup, estimates and procedure fees will be based on the provider's fee schedule.

On the Insurance Plan, set the following:

This method will generally provide the least accurate insurance estimates. Insurance estimates will be based on a percentage of the provider's fee schedule .