Payment Analysis inside an EOB¶
Every EOB and every patient on it has a Payment Analysis tab. It checks one thing: did the insurance company pay the contracted fee on this remittance?
It sits next to the posting work, but it is separate from it:
- Posting (Approve match, Post payment) is about getting the money into Open Dental.
- Payment Analysis is about whether that money was the right amount.
Payment Analysis never writes to Open Dental and never changes what you post.
Where to find it¶
| Level | Tabs | What Payment Analysis shows |
|---|---|---|
| Whole EOB (the patient list) | Posting · Payment Analysis | Every patient on the remittance, totaled. |
| One patient | EOB Review · Payment Analysis · Open Dental · Audit | That patient’s procedure lines, one by one. |
The rule¶
The same rule is used everywhere in Ordo. Per procedure:
| Step (as labelled in the formula) | Plain meaning |
|---|---|
| Patient’s share | Deductible plus coinsurance from the EOB. If those are missing, Ordo uses the EOB’s patient responsibility. |
| Clinic ↔ insurance contract | The contracted fee for this CDT code, from the insurer’s fee schedule mapped on the date of service. |
| What insurance paid | The paid amount. |
| Underpayment | Expected minus Paid, never below zero — where Expected is Contracted minus the patient’s share, also never below zero. |
Lines are calculated one at a time, then added up for the patient and the EOB.
The formula footer says it plainly: Billed (UCR) and EOB Allowed are shown elsewhere for context — they are not used in this underpayment number.
Example. Maria Santos, D2750 crown. Cigna contract: $865. Patient’s share: $432.50 (50% coinsurance). Expected: $432.50. Cigna paid $380. Underpayment: $52.50.
Whole-EOB Payment Analysis¶
Open a file, then click the Payment Analysis tab above the patient list.
- Click Run analysis (or Run again to refresh). The time shows as Analyzed at ….
- Read the cards: Status, Underpayment, Flagged procedures, Open work items.
- Scan the table: Patient, Lines, Contracted, Patient portion, Expected, Paid, Underpay, Status, Remarks.
- Click How calculated for the math on a patient, or Open to jump to that patient’s Payment Analysis.
Tick Show EOB context (not used in underpayment) to see Billed and EOB Allowed alongside — handy when talking to the payer, but they do not change the number.
Results are saved. Next time anyone opens the tab, the last run loads with the fee schedule, UCR schedule, and time it used. Run again after you fix a fee schedule or edit the extracted lines.
One patient’s Payment Analysis¶
Open a patient and click Payment Analysis. It loads the saved result, or runs automatically if there is none. Click Refresh to recalculate.
Each procedure line has a status:
| Status | Plain meaning |
|---|---|
| On contract | Paid what the contract says. Nothing to do. |
| Valid adjustment | Paid less, but for a normal reason. |
| Fee schedule review | Ordo could not find a contracted fee, so it cannot judge. |
| Internal posting | The gap looks like how the payment was recorded, not the payer. |
| Potential underpayment | Paid below the contract. Worth a look. |
When you see NA¶
NA means “Ordo cannot give an honest number here,” not “zero.”
| What shows NA | Why | What to do |
|---|---|---|
| Contracted, Expected, Underpay — status Fee schedule review, remark Missing clinic fee | No contracted fee was found for this insurer, code, and date of service. | Add or fix the insurer’s fee schedule or date map, then run again. See Fee schedules and date maps. |
| Patient portion, Expected, Underpay — remark Patient share unclear | The EOB’s deductible + coinsurance and its patient responsibility disagree by more than 50 cents, so Ordo cannot tell which is right. | Read the EOB line yourself. If a real gap remains, decide it in Review (below). |
Ordo does not treat it as unclear when the patient responsibility is simply billed minus paid — that is a common layout, and Ordo handles it.
Remarks you might see¶
| Remark | Plain meaning |
|---|---|
| Missing clinic fee | No contracted fee for this code on this date. |
| Patient share unclear | The EOB’s patient amounts disagree (see NA above). |
| Insurance paid more than contract | Paid above the contract. Usually fine — but check the fee schedule is current. |
| Contract fee doesn't match EOB | The EOB’s allowed amount differs from your contracted fee. Your schedule may be out of date, or the payer used the wrong one. |
| Paid more than EOB allowed | Paid is higher than the EOB’s allowed amount — often a reading or layout issue worth a glance. |
Work items and priority¶
A flagged procedure becomes a work item when the gap is at least $10 or 5% of expected. Work items also show up in Payment Analytics → Remittances, so an office manager can sweep them across many EOBs.
| Priority | When |
|---|---|
| Critical | Insurance was expected to pay something and paid $0. |
| High | Gap of $25 or more, or 10% or more. |
| Staff action | Gap of $10 or more, or 5% or more. |
Deciding a line (Review)¶
On a patient’s Payment Analysis, click Review on a flagged line. The Underpayment review dialog asks for a decision:
| Decision | Use it when |
|---|---|
| Confirm Underpayment | The payer really paid short. You plan to appeal or call. |
| Valid Adjustment | There is a normal reason (downgrade, alternate benefit, frequency limit). |
| Fee Schedule Incorrect | Our fee schedule is wrong, not the payer. Fix the schedule. |
| Not an Underpayment | Ordo flagged it, but it is fine. |
| Needs Manual Review | Someone else should look (for example the owner or billing company). |
A reason is required. The decision closes or updates the work item, so it drops out of the Needs review list in Payment Analytics.
Anyone who can open the EOB can run and read Payment Analysis. Recording a decision needs the Edit extracted data permission (Owners, Admins, and Reviewers by default).
Example: Monday at Bright Smile¶
- Jennifer posts Maria Santos’s Cigna payment as usual.
- She clicks the EOB-level Payment Analysis tab and Run analysis. Status shows one flagged procedure: Maria’s crown, Potential underpayment, $52.50, priority High.
- She clicks How calculated. Contract $865, patient’s share $432.50, paid $380.
- She opens Maria → Payment Analysis → Review, picks Confirm Underpayment, and types “Appeal sent to Cigna 3/9 — contract rate $865.”
- James Lee on the same EOB shows NA with Missing clinic fee on D0431. Cigna’s 2026 schedule has no D0431 line. Sarah adds it under Clinic settings, and Jennifer clicks Run again.