Should I use the fee allowed by the plan for each procedure or my own usual, customary and reasonable (UCR) fee ?

The reimbursement amount you receive as a participating provider with a dental plan is dictated by your contract with the plan and this amount will usually be less than your UCR. Unless a plan's contract actually prohibits it, you may submit claims using your full UCR. In fact, there is often an advantage in doing so.

Some plans base their fee allowances on claims data, setting allowances at a percentage of the average UCR for a region. Because the actual fees dentists charge determine some plan allowances, you should submit your usual fees on claims, rather than the allowance amount, to give the dental plans accurate data on the actual fees charged in your marketplace.

There is also an advantage in submitting your UCR in cases involving coordination of benefits between two payers. If the patient's primary plan is a preferred provider organization and the secondary coverage is a traditional insurance plan, the primary carrier will discount the amount it pays according to its contracted allowances, but the secondary carrier will likely calculate what it owes in balance based on the full amount you claim. In other words, if you file a claim to both carriers based on the discounted allowance of the first claim, you may be discounting yourself out of a higher reimbursement from the secondary plan.

Dental CPT Code Lookup.

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