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HMOs/DMOs with Supplemental Payments and Copays

This type of Insurance Plan is used for HMOs or DMOs with supplemental payments and co-pays. It tracks writeoffs and is common in Texas (e.g. CHIP, MCNA, DentaQuest, Medicaid).

Create a PPO plan that tracks writeoffs, then add a co-pay fee schedule.

  1. Create a normal Fee Schedule for the carrier. To calculate the fee for each procedure, add the insurance supplemental amount to the patient co-pay.
    (Insurance Supplemental Amounts + Patient Co-Pay = Procedure Fee).
  2. Create a co-pay fee schedule for the carrier, then for each procedure enter the patient co-pay.
    Note: If there is no fee, make sure to enter 0 or the patient will get charged the UCR fees (or set the blank entry default behavior in Family Module Preferences).
  3. On the Edit Insurance Plan window, set the following:
    • Plan Type: PPO Percentage
    • Fee Schedule: The carrier's normal fee schedule.
    • Patient Co-Pay Amounts: The carrier's co-pay fee schedule.
    • Benefit Information: Set benefits to 100% for all categories.

EXAMPLE: For Procedure A, DMO Insurance's will pay $90 and the patient has a co-pay of $10.

  • In the normal fee schedule, Procedure A will have a fee amount of $100 (insurance + co-pay).
  • In the co-pay fee schedule, Procedure A will have a fee of $10 (the co-pay).
  • To calculate insurance estimates, Open Dental uses the following equation:
    Procedure A normal fee ($100) – Procedure A co-pay fee ($10) = Insurance estimate ($90).

Troubleshooting
If you entered this kind of plan as a Capitation plan type with a co-pay fee schedule, follow these steps to fix it.

  1. In the Main Menu, click Setup, Fee Schedules. Add a normal fee schedule with a similar but not identical name to the existing co-pay fee schedule.
  2. For each procedure in the normal fee schedule, enter the fees using the following equation to determine the amount:
    (Patient Co-Pay + Insurance Supplemental Amounts = Procedure Fee). Make sure to enter 0 for all fees where there is no supplemental fee or co-pay.
  3. On the Edit Insurance plan window, change the following:
    Plan Type: PPO Percentage (from Capitation).
    Fee Schedule: The new normal fee schedule.
    Benefit Information: Set benefits to 100% for all benefit categories.

 

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