Allowed amounts and fee schedules

A payer doesn't pay from your fee. It pays from the allowed amount: the most it allows for that code. When you are in network, that amount comes from the fee schedule in your provider agreement with the payer, and the part of your fee above it is written off. That's why an estimate built from your fee alone can be off.

Where the allowed amounts come from

• Your fee schedule for each in-network carrier. In Settings › Insurance, each saved in-network carrier's card has a Fee schedule line. Click Upload and add the fee schedule from your in-network provider agreement: a spreadsheet, a PDF or a photo. We read a PDF or photo twice and keep only the amounts both reads agree on. Replace swaps in a new one; Remove takes it off.
• Medicare's fee schedule, for Medicare patients, for your office's area. We keep it current for you. (At a chiropractic office, Medicare's list covers the spinal adjustment codes 98940 to 98942, the chiropractic services Medicare pays for.)
• Medi-Cal Dental's schedule, for Medi-Cal patients at a dental office.

No fee schedule for a patient's plan? The estimate prices from your own fee, the way it always has.

Where you see them

• Under each code's price in an estimate or on a visit, for example: "Aetna allows $60 · Insurance pays $48 · Patient pays $12 · Write-off $40" for a $100 fee on a plan that pays 80%, with the deductible met.
• Allowed, a column in the coverage card on the patient's page.
• Allowed amount, rows at the bottom of the In-network vs out-of-network card.

How the math works

• The estimate starts from the lesser of your fee and the allowed amount.
• Any deductible left, then the plan's share, are worked out on that amount.
• In network, the part of your fee above the allowed amount is written off. Nobody pays it, and the estimate shows it as Write-off.
• Out of network, the patient owes the part of your fee above what the plan allows.
• When your fee is already below the allowed amount, the line says so ("your fee is lower") and nothing is written off.

Out of network: only the patient's own plan

Out of network, there is no fee schedule. What a plan allows is set by the plan itself (often by the employer that bought it), so one insurer can allow very different amounts on different plans. So we show an out-of-network amount only when it is about that patient's own plan:

• your office's own amounts on that plan, from your payment letters (EOBs) or from what the insurer publishes for your office;
• the plan's own rule, when it pays a set percent of Medicare's amount;
• for a Medicare Advantage plan, Medicare's own amount, which the rules require.

These amounts read "allows about". When the plan once allowed your whole charge, the line adds "(it allowed your full charge, so its limit may be higher)". When nothing is known for the patient's plan, no amount is shown. The In-network vs out-of-network card may say what that insurer's other plans allowed your office, as a range, but that range is never used in the math.

To add your own out-of-network amounts, open Settings › Insurance, find the saved out-of-network carrier, click Upload an EOB, and drop a payment letter from that carrier. We read the codes and the amounts it allowed your office, never the patient.

Frequently asked questions

Do I have to upload a fee schedule? No. Without one, estimates price from your own fees. With one, they match what the payer will really pay.

Our fee schedule changed. Click Replace on that carrier's Fee schedule line and upload the new one.

Is this sent to the carrier? No. Fee schedules and allowed amounts stay with your office, and they are used to price your estimates.