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Canada: Setup Insurance Categories

Canada insurance categories allow automatic calculations of insurance coverage based on the procedure code. Changes affect Benefit Information for ALL insurance plans. Do not alter insurance categories unless you understand what you are doing. 

In the main menu, click Setup, Family/Insurance, Insurance Categories.

The insurance categories above are the recommended setup for Canada.

Note: If your spans contain Part A, Part B, Part C, and Endo, you can convert to the recommended setup. See Convert Four-Part Insurance Categories to Default Insurance Categories at the bottom of this page.

Coverage Categories:  Coverage categories have specific procedure code spans attached according to typical insurance groupings. Categories are used to calculate the actual insurance coverage for specific procedures.

  • To reorder categories, click the up/down arrows. The General category should be at the top, because it keeps track of annual maximums for all patients. 
  • To add a new category, click Add, or double click a category row to edit.
  • Do not click Set to Defaults as this will change all categories to U.S. default categories.



  • Description:
  • Default Percent:  The percentage default for new Insurance Plans. Changing this number only changes the default value for future insurance plans. It does not affect any patient records.
  • Is Hidden:
  • Electronic Benefit Category:  You must have exactly one of each E-benefit category.  There can be no duplicates and no missing categories.

Coverage categories are completely unrelated to procedure code categories in Definitions.

Coverage Spans:  Each coverage category can have unlimited spans of procedure codes attached. The default spans should work for most offices.  Adding extra spans does not increase complexity for the staff. They will still only see the coverage categories set up. Spans simply allow you to put whatever procedures you want into each category. A span can be as short as a single code. Spans can be deleted although this will affect patient data if the span includes a patient's procedure (it does not corrupt the data). Changes to spans will affect the treatment plans of multiple patients.

To add a coverage span, click Add Span, or double click a coverage span row to edit.

Open Dental warns you if the code is not in the correct CDA format (at least the first 5 digits), but you can still use such codes if you wish.

If you have a category that is a subset of another span, then that category should be lower in the list.

Convert Four-Part Insurance Categories to Default Insurance Categories
To convert the default spans to the recommended set, use the steps below. If you have different spans, these instructions may not be correct.



  1. Rename Part C category to Ortho.
  2. Add new categories to match the categories shown on the Edit Insurance Category window above. Do not add Endo and Ortho because they already exist. Do not change Part A or Part B. For each new category, select the electronic benefit category and enter a default percentage.
    • The Category and E-Benefit Category must match exactly.
    • The default category percentages affect all patients. Do not change any default percentages from their old values unless you are certain they were wrong. Use the percentage values from Part A and Part B for reference.
Category Electronic Benefit Category Default Category Percentage
Ortho (no changes needed) Ortho No changes
Endo (no changes needed) Endo No changes
General General leave blank
Diagnostic Diagnostic use the percentage from the old Part A
X-Ray DiagnosticXRay use the percentage from the old Part A
Preventive RoutinePreventive use the percentage from the old Part A
Restorative Restorative Probably use old Part A percentage. Might be Part A.
Crowns Crowns use the percentage from the old Part B
Perio Periodontics use the percentage from the old Part A
Prosth Prosthodontics use the percentage from the old Part B
Maxillofacial Prosth MaxillofacialProsth use the percentage from the old Part B
Oral Surgery OralSurgery use the percentage from the old Part A
Adjunctive Adjunctive leave blank
Accident Accident leave blank

  1. Use the up/down arrows to change the sort order of categories to match the Setup Insurance Category window above. Place Part A and Part B categories between General and Diagnostic. The first 4 categories must be in the following order:
    • General
    • Part A
    • Part B
    • Diagnostic
  2. Manually change the code spans for each category to match the Setup Insurance Category window above. Do not modify your existing coverage spans for Part A or Part B.
  3. Hide the Part A and Part B categories. Double click on the category row, then check the Is Hidden box.

The resulting insurance category spans will look like this:

As new insurance plans are added, they will only use the new insurance categories. Part A and Part B categories will not be used.

Existing insurance plans will continue to use the old insurance categories and percentages unless the plans are manually edited. To do so, we recommend changing insurance plan Benefit Information via the Insurance Plan List (Lists, Insurance Plans) so all subscribers are affected by the change.

 

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