PPO fee schedule: UCR fees vs allowed amounts
A PPO fee schedule is the list of fees, one per CDT code, that an in-network practice agrees to accept from a dental plan as payment in full. Each fee is the allowed amount: the plan pays its share and the patient the rest. The gap up to the office’s own fee, its UCR fee, is written off.
Also calledFee scheduleAllowed amountContracted feeMaximum allowableUCR
By Dr. Maya Arnaout, DDS, VP of RevenuePublished 3 min read
What is a PPO fee schedule?
When a practice signs a PPO contract, it gets the plan’s fee schedule: a maximum fee for each CDT code. For that plan’s patients, the fee is the most the practice can collect for the procedure, from the plan and the patient combined.
Each payer has its own schedule, and one payer can have several, by network, plan or region. Schedules change when contracts are renewed or renegotiated, so the copy loaded in your PMS can fall out of date.
What is the difference between UCR and the PPO allowed amount?
UCR stands for usual, customary and reasonable, and it is used two ways:
- The office’s UCR fee is its own full fee for a procedure, what it charges before any insurance discount.
- A payer’s UCR amount is what the payer considers a usual fee in the area. Plans use it to pay out-of-network claims.
| Compared on | Office UCR fee | PPO allowed amount |
|---|---|---|
| Set by | The practice | The plan, in the network contract |
| Applies to | Every patient, before any discount | That plan’s patients, while the practice is in network |
| Shows on the ERA or EOB as | The billed amount | The allowed amount |
| What it is used for | The starting point: the difference down to the allowed amount is written off, usually as CO-45 | The base for the plan’s share and the patient’s share |
Out of network there is no contract and no contractual write-off. The plan pays on its own allowed amount, and the practice can usually bill the patient the difference, subject to state law and the plan’s terms.
How do you find underpayments against the fee schedule?
Compare the allowed amount on every ERA or EOB line with the contracted fee for that CDT code. When the allowed amount is lower and nothing on the remittance explains it, the plan has underpaid.
D0120 Periodic exam
Matches the contract
Office fee$65.00Contract$45.00Allowed$45.00D1110 Adult cleaning
Matches the contract
Office fee$120.00Contract$90.00Allowed$90.00D0274 Four bitewing x-rays
Matches the contract
Office fee$85.00Contract$62.00Allowed$62.00D2392 Two-surface back tooth filling
Allowed $14.00 under contract
Office fee$210.00Contract$140.00Allowed$126.00
One line of four was allowed below the contracted fee. It goes on the list of claims to dispute with the payer.
Not every lower payment is an underpayment: deductibles, frequency limits, the annual maximum and alternate benefits lower what the plan pays without changing the allowed amount. The underpayments guide covers the causes, how to tell a CO-45 write-off from a short pay, and how to dispute in batches.
How ScoutIQ handles it
ScoutIQ checks each line of every ERA and paper EOB against your contract as it posts. Short pays go to their own queue with the payer’s reason and the days left to appeal, and Atlas ranks payer underpayments in the team’s daily work and drafts dispute letters for a person to approve. Your team sends the dispute.
Insurance Billing Automation
ERAs and EOBs read; EFT, check and card payments reconciled.
See Insurance Billing Automation