EOB
A written statement sent to the patient and the provider that explains how the claim was adjudicated.
UCR
Usual, Customary, Reasonable
Standard office fees—what you would charge a cash patient.
Fee Schedule
A fee schedule is simply a table of CDT codes and dollar amounts.
What are the four main fee schedules?
UCR, PPO, Medicaid, Copay
Who provides fee schedules?
Practice maintains UCR; not provider-specific
Insurance carriers publish allowed schedules
Discount plan (if used) patient-pay schedules
Prophys & Fees
D1110 prophylaxis - adult
D1120 prophylaxis - child
Accounts Receivable (A/R)
Total outstanding balances owed to the practice from insurance carriers and patients for services rendered.
Days Sales Outstanding (DSO)
Average days to collect payment after service delivery. Target: 30-45 days for optimal cash flow.
Net Collection Rate (NCR)
Percentage of collectible revenue actually collected. Formula: (Total collections ÷ [Total charges - contractual adjustments]) × 100. Benchmark: 98-100% after write-offs.
Aging Buckets
Categorization of A/R by time outstanding: 0-30, 31-60, 61-90, 90+ days.
Clean Claim Rate
Percentage of claims accepted on first submission without errors. Target: 90%+ for efficient RCM.
Contractual Adjustment
Write-off difference between office fee and payer’s allowed amount for in-network providers.
ERA (Electronic Remittance Advice)
Digital version of EOB (ANSI 835 file) detailing claim payments electronically.
Fee Schedule
Predetermined fees for services; practices maintain multiple schedules (Medicaid, PPO, UCR) in Open Dental.
Current Medicaid Model:
• Collection rate: 95%
• Clean claim rate: High (manual verification reduces errors)
• Patient A/R: Minimal (Medicaid covers services fully)
• Insurance A/R: Primary focus
PPO Model Target KPIs
collection rate: 98-100%
• A/R aging: ≤20% over 60 days
• First-pass resolution: 90%+
• DSO: 30-40 days
• Patient portion collection: 85%+ at time of servic
