Insurance term
Downgrade (Alternate Benefit)
Definition
A downgrade, or alternate benefit, is a plan rule that pays for a less expensive treatment than the one performed.
Why it matters for the front desk
Common examples are paying a back tooth composite filling at the amalgam rate, or a ceramic crown on a molar at the metal crown rate. The patient usually owes the difference, within the limits of the office's network contract and state rules. Downgrades rarely show up in a basic eligibility check, so ask about them for any restorative treatment plan. Patients accept the cost more readily when it's explained before treatment.
Related terms
- Coinsurance Coinsurance is the percentage of a covered procedure's cost that the patient pays after the deductible, with the plan paying the rest.
- Preauthorization (Predetermination) A preauthorization, usually called a predetermination or pretreatment estimate in dentistry, is a request sent to the payer before treatment asking what it will cover.
- UCR (Usual, Customary and Reasonable) UCR is the amount a payer considers a usual, customary and reasonable fee for a procedure in a given area, used to set its allowed amount.