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Setup Insurance Categories

Insurance categories allow automatic calculations of insurance coverage based on the procedure code. 

Do not alter insurance categories unless you understand what you are doing.  Some changes affect Benefit Information for ALL insurance plans.  The only known reason to change insurance categories is if you are in a country other than the United States.

In the Main Menu, click Setup, Family/Insurance, Insurance Categories.

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. The categories that exist affect the categories available when creating a Benefit.

  • To revert to Open Dental defaults, click Set to Defaults.  
  • 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.

Description: The category name.
Default Percent:  The category's default percentage when creating a new Insurance Plan. Changing this number only changes the default value for future insurance plans and does not affect existing patient plans. If the percent is left blank, this category will not show as a default benefit in new insurance plans.
Is Hidden: Remove this category as a selection option on the Edit Benefit window.
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 ADA 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.

Frequently Asked Questions
Question: How do I add or increase the code span for an insurance category? For example, I want the Prosth insurance category to include codes D6920 - D6999.
Answer: Select the category row, click Add Span, then enter the code span.

Question: Why is there no category for implant services (codes D6000-D6199)?
Answer: Implant services are typically included in the General insurance category, but you can add an implant category if you want. Note that there is no implant e-benefit category however. You have two options:

  1. Add an implant coverage span under Prosth. In this case implants will use the Prosthodontics e-benefit category.
  2. First create a separate implant category. Enter the description (Implant), percentage, but do not select an e-benefit category.
    Then add the implant code span.
    If you use this method, all new insurance plans you create will have an 'Other Benefit' row for the new implant category. See Benefit Information.


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