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Calculating Insurance Benefits

Calculating Insurance Benefits

As we all know dental insurance companies work on a percentage basis (this is why you can only estimate their payments). The percentage paid is based on the insurance plan of a particular group or individual and varies widely.

There is almost always a deductible that the patient has to meet before the insurance percentage kicks in and the deductibles vary.

With electronic verification much of the work is done for you. Benefits can often be verified in real time  through the provier's web site or bu uinsg a paid service. If you're not using such a service you should be. For those offices that verify by phone or fax the following is the basic procedure for estimating the patient's co-pay.

To calculate the insurance benefit take the estimated insurance allowance and multiply it by the percent the insurance company will pay. The total gives you the estimated insurance benefit.

(Estimated Allowance) x (percentage pd. by insurance co.) = insurance benefit.

EXAMPLE: $60.00 filling X 80% = $48.00 paid by the insurance company.

If the deductible hasn't been met, you must subtract the deductible FIRST. Then multiply it by the percentage.


$385.00 Crown

-$50.00 Deductible


=$335.00 left multiplied by 50% (% paid by ins. co.)

=$167.50 paid by insurance.

=$217.50 Patient Portion ($167.50 + $50.00)

The patient portion is always collected at the time of service.

Verifying Benefits
Interacting With Patients

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