Medical Insurance

Out-of-Network Benefits?

Always OON. Pays % of UCR after deductible. Independent of dental.

Rem. Deductible

Plan Pays %

Allowable Basis

Primary Dental

Insurance Network

—

Rem. Annual Max

Rem. Deductible

Waive ded. for Diagnostics/Preventive

Secondary Dental

Insurance Network

—

COB Method

Rem. Annual Max

Rem. Deductible

Waive ded. for Diagnostics/Preventive

ICD-10 Diagnosis Triggers & Logic Gates

C-Codes (Cancer)

D-Codes (Neoplasms)

S-Codes (Trauma)

M26 (TMJ)

Q-Codes (Congenital)

L03 (Cellulitis)

K12 (Abscess)

K01.1 (Impacted Teeth)

K09 (Cyst)

K10.2 (Osteitis)

Add Procedure

Procedure Code / Bundle

Covered by Plan?

Total Gross Billed

$0.00

Patient Out-of-Pocket

$0.00

Provider Collected
$0.00

Billed fee: In-network → contracted fee. OON → UCR billed. Write-off is silent.
Medical (always independent): Medical and dental do not coordinate. Medical applies its deductible to UCR/allowable then pays its %.
Primary dental deductible: Applied to contracted/allowable, waivable for D&P.
Primary dental coinsurance: Plan pays % of (allowable − deductible), capped at remaining annual max.
Downcoding: Enter plan's downgraded allowable. Coinsurance applies to the lower amount.
MTC flag: Zeros dental coverage on implant/graft lines. Medical is unaffected.
Standard COB: Secondary pays lesser of (a) its own normal benefit or (b) patient's remaining dental balance after primary.
Non-Duplication: Secondary pays $0 if primary ≥ secondary's own-as-primary benefit.
MOB/Carve-out: Secondary pays (its benefit − primary paid), min $0.
Patient responsibility = Billed − all payer payments, min $0.
VOB Import (v3): Per-code coverage %, covered/not-covered status, downgrade amounts, medical-first flags, and chart # all auto-populate from VOB file.

Treatment Plan Estimator v3

Itemized Treatment Estimate