Insurance Plans  

To create a new insurance plan, go to the Family module and click on the Add Insurance button in the toolbar. 

If you click yes, you can either attach to an existing plan for this subscriber, or create a new plan. If you click no, you will be able to choose the subscriber from all patients in the database. If you are creating a new plan, just remember that you can never change the subscriber later, so be sure you know who the subscriber is.

The window is divided into two main sections. The top is patient information, and the bottom is insurance plan information. Within the larger section, there are many subsections surrounded by group boxes.

Patient Information
The background color is set from Definitions | Misc Colors | Family Module Coverage. The same color is used in the Family module for this information. This is information that is specific to the patient rather than the insurance plan itself. In the database, this information is stored in a table called 'patplan'. If you are editing a plan which is not necessarily attached to any patient as current coverage, then this upper section might be blank.

The optional patient ID is only used for some plans which assign an ID to each patient in addition to the main subscriber ID. Otherwise, the ID is usually the SSN, or simply the name and birthdate. Order refers to whether this is primary or secondary insurance. So you can at any time change this number to rearrange which plan is set as primary, secondary, or supplemental. Pending can be used if you have not yet finished verifying insurance, but you want to get some insurance entered anyway. It is informational only, and does not change any functionality of the program. If you don't even know the name of the insurance company, but you want to signify that the patient has insurance, you can create a dummy carrier called 'Pending'. Also check this box. Then, come back later and fix it.

Adjustments to insurance benefits are typically used if the patient has already had treatment done at another office this year or if you have just converted to Open Dental. You will need to make an adjustment to account for the amounts used so far. Click the add button at the upper right.

Employer and Carrier Name
A carrier name is always required, but employer is optional. The 'Pick From List' button will take you to the Ins Plan List, where you can choose from an existing list.

Identical Plans
The identical plans box shows the number of identical plans as well as the names of the subscribers for those plans.  In Module Setup, in the Family module section, there is the following option:
"InsPlan option at bottom, 'Change Plan for all subscribers', is default"
This option should normally be checked to prevent spawning of duplicate insurance plans. If the radio button at the bottom is set to "Create new plan if needed", it will be triggered by a change in any of the fields on the left.  This includes GroupName, GroupNum, PlanNote, FeeSched, PlanType, ClaimFormNum, UseAltCode, ClaimsUseUCR, CopayFeeSched, EmployerNum, CarrierNum, AllowedFeeSched, TrojanID, DivisionNo, IsMedical, FilingCode, DentaideCardSequence, ShowBaseUnits, CodeSubstNone, IsHidden, MonthRenew, FilingCodeSubtype, and CanadianPlanFlag.  A new plan will not be triggered by changing Benefit information at the right. Changed benefits are always at the plan level, so they apply to all subscribers.

General Plan Information
If an insurance company accepts E-claims, then you should fill in the Electronic ID that they give you. If the carrier does not accept electronic claims, then you have two choices. One option is to leave the Electronic ID blank and submit the claims electronically anyway. If the clearinghouse cannot match the insurance carrier name with a known name, then the claim will be printed by the clearinghouse and mailed. If you prefer to mail these types of claims, then check the box next to the Electronic ID. When you are Sending Claims, it will be easy to see which claims to print and which ones to send electronically.

There are four choices for plan type. If you select Category Percentage or PPO Percentage, then the plan percentages section on the right side of the window will be in effect. If Flat Co-pay is selected, then all categories will be computed at 100% coverage. Use this option for Medicaid. The Capitation option is used for HMO and DMO type plans. See the section on Types of Insurance Plans for more information about how to set up the different plan types.

If your insurance plan uses alternate procedure codes, as some Medicaid plans do, you can check the Use Alternate Code box to use those codes when submitting insurance claims. Alternate procedure codes for each procedure are set up in the Procedure Code edit window. If this is a Medical Insurance plan rather than dental, then check the Medical Insurance box. This box is not normally visible, and must be turned on in Show Features.

Don't substitute code (e.g. posterior composites): The substitution codes are set globally in the Procedure Code edit window. The checkbox in this window lets you enable/disable this feature on an individual plan basis.

Some insurance companies ask you to submit your UCR (Usual Customary and Regular) fees on insurance claims instead of the fee you actually charged the patient. When you check that box, the fee billed to insurance will be based on the fee schedule of the default provider for the practice. The fee will be clearly visible in the Claim Edit window, and you will still have the option to change it manually before sending the claim.

The hidden checkbox means that you don't want this insurance plan to be copied for use by other subscribers.  If the box is checked, it will not show in the list when the Pick From List button is used.

At the lower left is the fee schedule list. You have the option to select a fee schedule which will override the fee schedule for that patient. See the Other Fee Schedules section further down on this page for information on how to use the other two fee schedules.

The Claim Form list lets you select the actual claim form to be used to print. It does not affect electronic claims. You can add your own claim forms (with some effort). See the Claim Forms section for more information.

Subscriber
The subscriber is set when first creating the insurance plan, and cannot be changed later. The subscriber ID will be automatically filled in with their SSN, but can be changed if needed. Some insurance companies do not use the SSN to keep track of their subscribers, but use an alternate number instead. The Subscriber ID is not allowed to be blank. If the patient has Medicaid, you should also fill in the Medicaid ID from within the Patient Edit window.

Date Effective and Date Terminated are filled in with the appropriate dates if known, or they can be left blank if unknown. But if the plan uses service year instead of calendar year, then you must fill the start date with the correct value. In that case, all benefits will be calculated based on start date rather than January first. See the benefits section below for an explanation of the difference between service year and calendar year.

Release of Information:  This box gets checked if the patient has signed a form that states that the patient consents to the use and disclosure of protected health information to the insurance company in order to carry out payment activities.  If checked, then "Signature on File" will show in box 36 of the claim form.

Assignment of Benefits: This box gets checked if the patient has signed a form that states that they authorize and direct payment of the dental benefits otherwise payable to the patient, directly to the dental office. There are a few offices that make patients pay up front and the insurance checks get mailed to the patient. For those offices, this box would be unchecked.

If the insurance is still effective, you leave the Date Term field empty.

Other Fee Schedules
In addition to the regular fee schedule for the insurance plan, there are also two other types of fee schedules: co-pay and allowed. They are described on the Fee Schedules page.

Request Electronic Benefits
This area is for Electronic Benefits as well as Trojan or Insurance Answers Plus.

Benefit Information

See Benefit Information.