Haris Ashley
Open Dental is a software that allows users to manage medical and dental insurance plans, claims, and payments. It offers a range of features, including the ability to create and edit insurance plans, designate insurance categories, and calculate insurance estimates. Users can also use Open Dental to generate and send medical and dental claims, as well as to receive and finalise insurance payments. To enter medical insurance in Open Dental, users must first enable medical insurance in the software's settings. They can then create a new insurance plan, enter relevant codes, and designate the plan as medical insurance. This process involves checking the Medical Insurance box and selecting the appropriate claim form. Once the medical insurance plan has been set up, users can enter patient information, associate them with the plan, and manage their claims and payments.
| Characteristics | Values |
|---|---|
| Enabling medical insurance | Check the Medical Insurance box in the Plan Info tab |
| Claim form | Change to a medical claim form (e.g., "1500_02_12") in the Other Ins Info tab |
| Printing and mailing claims | Use pre-printed forms due to the red background; claim data will print to the proper areas |
| Charting procedures | Double-click into the procedure and click the Medical tab; only dental procedures need to be charted if cross-coded to medical codes |
| Creating medical codes | Go to Lists, Procedure Codes, click +New, and cross-code CPT codes with ADA codes |
| Clearinghouses | Set a default medical/institutional clearinghouse separate from the dental default |
| Sending claims | Send batches of claims to one clearinghouse at once |
| Finalizing payments | Use the Claim Only option for a single claim or the Batch option for multiple claims |
| Adding insurance | In the Family Module toolbar, click Add Insurance and specify if the current patient is the plan subscriber |
| Selecting insurance plan | If the patient is a subscriber, a blank Insurance Plan opens; select an existing plan or create a new one |
| Benefit year | Check the box if the plan follows the calendar year; otherwise, uncheck and enter the month when benefits renew |
| Annual maximum | Enter the maximum annual amount insurance pays per individual or family |
| General deductible | Enter the amount the individual or family must pay out of pocket before insurance coverage begins |
| Orthodontic benefit | Enter the maximum orthodontic benefit, separate from individual and family annual maximums |
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What You'll Learn
Adding insurance payments
Open Dental Software offers a range of functionalities to help users manage insurance payments. Here is a step-by-step guide on how to add insurance payments:
Entering Insurance Payments
Firstly, enable the 'Show Patient Responsibility' column in the Edit Claim/Payment windows in Preferences. This will help you see the 'Pat Resp' column when entering EOBs. This feature will automatically calculate the patient's portion based on the 'Ins Pay' and 'Write-off' amounts entered in the same line item.
Finalising Payments
Once you have posted your payment (by procedure or as a total), you will be given two options to finalise the payment: 'Claim Only' and 'Finalize Payment'. 'Claim Only' is used for posting a payment from insurance for a single claim. The insurance-paid amount will automatically appear in the 'Enter Payment' window. Here, you can add or edit payment details as needed, and click 'OK' to continue.
Batch Insurance Payments
Open the Batch Insurance Payments window and click 'Add'. Enter the payment amount and any additional payment details. Next, enter the 'Carrier Name' to narrow down the claims in the next window. Sent claims or received claims with unfinalised payments, matching the carrier you've entered, will be listed in the All Outstanding Claims grid at the bottom of the window.
Attaching Claims to EOB
Highlight a claim from the 'All Outstanding Claims' grid and click to attach it to the 'Batch Insurance Payment'. The claim will be moved to the 'Attached to this Payment' grid. Continue attaching or receiving claims until all necessary claims are attached to the EOB. Individual claims are finalised as they are attached to the payment.
Insurance Payment Plans
Insurance Payment Plans can be used to track expected insurance payments, such as insurance instalment payments. In the Account Module, the Payment Plans grid shows these plans with the type 'Ins'. To create a new Insurance Payment Plan, click on 'Payment Plan, Insurance Payment Plan' in the 'Account Module'. Assign a category to this payment plan, such as 'Ortho' or 'Implant'. This helps to distinguish one payment plan from another, especially when families have multiple plans.
Adjustments to Insurance Benefits
Adjustments to Insurance Benefits can be added when a patient uses benefits outside of the practice. In an Insurance Plan, click 'Add' in the upper right corner. This will adjust the benefits used to reflect proper Insurance Remaining Calculations and Treatment Plan estimates. Once the patient's benefit year is up, the amount entered will no longer affect estimates but will remain listed for future reference.
These steps should help you effectively manage and add insurance payments in Open Dental Software.
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Creating a new insurance category
Open Dental is a software that allows you to create and edit insurance plans for your patients. Here is a step-by-step guide on how to create a new insurance category in Open Dental:
Step 1: Access the Insurance Categories Menu
Go to the "Setup" menu, click on "Advanced Setup", and then select "Show Features". This will open a window where you can enable or disable various features.
Step 2: Enable Medical Insurance
In the "Show Features" window, make sure to check the box for "Medical Insurance". This will allow you to create a new insurance category specifically for medical insurance plans.
Step 3: Create a New Category
Go to the "Setup" menu again, and this time select "Definitions" and then "Proc Code Categories". Here, you will see a list of your existing categories. Click on the "Add" button to create a new category.
Step 4: Name the New Category
A new window will pop up, prompting you to enter the details of the new category. Start by entering a name for your category. This could be something like "Medical Insurance Plans" or any other name that best describes the category.
Step 5: Set the Default Percent
The "Default Percent" field determines the coverage percentage assigned to the category when creating a new insurance plan. You can leave this blank if you don't want this category to be added as a default benefit to new insurance plans.
Step 6: Configure Additional Settings
The "Is Hidden" setting allows you to remove the category as a selection option on the "Edit Benefit" page. You can also set an "Electronic Benefit Category", which corresponds to a fixed row in the Benefits window.
Step 7: Add Procedure Code Spans (Optional)
Each category can have unlimited procedure code spans attached. A span can be as short as a single code. To add a new span, highlight a grey category row and click "Add Span". You will then be able to enter the starting and last procedure codes for the span.
Step 8: Save the New Category
Once you have entered all the necessary information, click "OK" to save the new insurance category.
Remember that creating a new insurance category is just the first step. You will also need to create or add specific insurance plans within this category for your patients. Open Dental provides a range of tools to manage insurance plans, including adding new plans, editing existing plans, and processing plan changes.
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Cross-coding with ADA codes
To enter medical insurance in Open Dental, you will need to create medical codes that can be cross-coded with ADA codes. Here is a step-by-step guide on how to do this:
- Go to "Lists" and then "Procedure Codes".
- Click "+New" to create a new medical code.
- Click "Add" after entering the new medical code. If you are adding multiple medical codes, you can quickly move to the next code by clicking "Add" again.
- Now, cross-code the CPT code with the ADA code.
- Go back to the "Procedure Codes" list and find the corresponding dental code. Double-click on it to open the "Edit Procedure Code" window.
- Enter the CPT code in the "Medical Code" box.
- Repeat this process for each dental procedure that has a corresponding medical code.
- Download the latest ICD-10 codes by going to "Setup", "Chart", and then "EHR". Click on "Code System Importer" and then "Check for Updates".
- Highlight "ICD10CM" and click "Download Updates".
- These updated ICD-10 codes will be imported into your database.
It is important to note that only dental procedures need to be charted if they are cross-coded to medical codes. If dental procedures and medical procedures are charted separately, it may result in double-billing the patient. When a claim is created as "Medical", any procedures cross-coded with medical codes will be billed using these procedure codes instead of dental codes.
Additionally, if a patient has medical insurance, this insurance will be billed first for cross-coded procedures. This is because there are no maximum benefits for medical insurance, and there is often no deductible. By creating a medical claim first, you can take advantage of these conditions.
To set up medical cross-coding, you need to link the ADA codes to the AMA codes. For each ADA code, mark it for medical cross-coding and then add the desired AMA CPT codes. The AMA CPT codes are not included in the software for legal reasons but can be purchased separately.
Once you have set up medical cross-coding, you can create a medical claim by entering the patient's medical insurance information in their Family File. Double-click on the Insurance block, click on the "Medical Insurance" tab, and enter the insurance information. With the Insurance Information dialog box open, click on "Insurance Data".
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Printing and mailing claims
Printing and mailing medical insurance claims on Open Dental is a straightforward process. Firstly, ensure that you have set up a medical insurance plan for your patient. To do this, enter the insurance plan as usual, but make sure to check the 'Medical Insurance' box in the Plan Info tab. In the Other Ins Info tab, select the claim form for the plan, usually the "1500_02_12" form, which is the updated HCFA 1500 form. It is important to note that HCFA 1500 Claims must use pre-printed forms due to their red background, and the background will not be printed by default when using Open Dental.
Once the insurance plan is set up, you can start creating the claim. On the Claim Misc tab, you will find the Prior Authorization field, which is rarely used. The Insurance Plan field is crucial and must be set correctly when creating the claim as it cannot be changed later. If you attach the claim to the wrong insurance plan, you will have to delete it and start over. The Relationship field indicates the patient's relationship to the plan's subscriber, based on the value set in the patient's Edit Insurance Plan Window.
When entering claim information, be mindful of the Med/Dent setting. If your patient has a dental insurance plan listed first and a medical insurance plan listed second, the Ins Est column may be misleading as it will always show 0, indicating dental insurance estimates. To avoid this, ensure that the medical plan is listed first in the Family Module. Additionally, dental and medical e-claims are limited to 50 procedures, and printed ADA claim forms are limited to 10 procedures. If more procedures need to be included, you will need to create a separate claim.
After you have entered all the necessary claim information, you are ready to print and mail the claim. In the Main Menu, go to Setup, Family/Insurance, and Claim Forms to access the printed claim form settings. Here, you can customize the form or use one of the internal templates provided by Open Dental. Once you are satisfied with the form, select the claims you want to print, and click Print. You can also print blank versions of the default claim form if needed.
To track the status of your printed claims, Open Dental offers the Outstanding Insurance Claims Report. This report helps you monitor claims that have been sent but not yet received. You can update the tracking status, filter claims by age or date range, and assign them to users for follow-up. Additionally, you can export the list of claims as a TXT or XLS file or send it to your default printer.
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Clearinghouses
There are a number of clearinghouses integrated with Open Dental to send claims electronically. Users should first sign up with their selected clearinghouse and then set up the clearinghouse in Open Dental. It is important to note that dental clearinghouses cannot accept medical or institutional claims. Therefore, a default medical/institutional clearinghouse must be set, separate from the dental default.
When sending claims for clinics, the clinic-level overrides are used instead of the default settings. These are determined by the claim's assigned clinic. The default dental or medical clearinghouses remain the same for all clinics. To access the settings for each clinic, double-click the clearinghouse row to open the Edit Clearinghouse or Direct Carrier window. All other options are only enabled when the Unassigned/Default clinic is selected. First enter settings for the clinic Unassigned/Default. These settings are used by all clinics if no clinic-level overrides are entered.
When choosing a clearinghouse, it is important to ensure that it is HIPAA certified and compliant. The clearinghouse should provide remote access via a secure VPN to your dental practice computer or server. This makes the connection HIPAA compliant. It is also beneficial to consider a clearinghouse that has earned HITRUST certified status for information security. This certification indicates that the company has passed a comprehensive security evaluation and has met all industry requirements and regulations.
Additionally, the ideal clearinghouse partner should provide thorough staff training and highly responsive customer support. A knowledgeable customer support team is essential for building trust and reliability. It is also recommended to ask for referrals from current customers or fellow dental professionals to help make an informed decision.
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Frequently asked questions
First, check the box to enable Medical Insurance in Show Features. Then, in the Family Module toolbar, click Add Insurance. If the current patient is the plan subscriber, click Yes. If not, click No and select the subscriber. If the subscriber is a non-family member, click More Patients to select anyone in the database as the subscriber. Once a subscriber is selected, select the insurance plan or create a new one. Finally, check the Medical Insurance box in the Plan Info tab.
After entering the insurance plan, you can enter payment details. The insurance paid amount will automatically appear in the Enter Payment window. You can then add or edit payment details and click OK to continue.
Go to Lists, Procedure Codes, and click +New. Then, create the medical codes you will be using so they can be cross-coded with ADA codes. After that, cross-code the CPT code with the ADA code. Find the corresponding dental code in the Procedure Codes list and double-click to open the Edit Procedure Code window. Enter the CPT code in the Medical Code box.
