In the Main Menu, click Setup, Family/Insurance, Insurance Blue Book.
See our video: Blue Book Webinar
Blue Book allows for more accurate estimates for out-of-network (Category Percentage) insurance plans.
- Users set up Blue Book in this window to determine the best method for estimating procedure fees.
- As claims are received, users enter the allowed fee from the EOB into the claim.
- Open Dental uses the allowed amounts, and the criteria set in this window, to determine the fee for treatment planned procedures.
Blue Book Feature: There are three options when estimating fees for out-of-network insurance plans. Select your desired method from the list. Also see Blue Book.
- None: (default) This method requires users to manually create out-of-network fee schedules for accurate insurance estimates.
- Legacy Blue Book: This method uses the legacy version of Blue Book. For each carrier associated with an out-of-network plan type, an out-of-network fee schedule (named by carrier) is automatically created. The new fee schedule is attached to the insurance plan.
- Blue Book: This method uses the logic selected in this window to determine the estimated fee for a procedure. Fee schedules are not created using this method which makes managing fee schedules easier and determining estimates more automated.
Blue Book Settings: These settings pertain to the Blue Book feature (does not affect Legacy).
- Use Insurance Plan in hierarchy: When unchecked, the Allowed fees from received claims for matching Insurance Plan is disabled in Hierarchy rules.
- Insurance Blue Books Rules Hierarchy: See below for details.
- Allowed Fee Method: Determines which method is used to calculate procedure fees. Options are:
- Median: Use the middle value of the allowed amounts entered in the selected time frame.
- Average: Average the values of allowed amounts entered in the selected time frame.
- Most Recent: Use the most recent value entered in the allowed amount.
- UCR Fee Percent: The percentage to cover of the UCR fee. When the UCR fee rule is in use, it will apply this percentage to the covered amount of the UCR fee.
- For example: If a $100 procedure is set to cover 80% (as set in the insurance benefits), the UCR fee rule will cover 80% of the remaining $80 ($64).
- Allow anonymous fee sharing: Check to allow sending anonymous fee data to Open Dental HQ. No PHI is sent, only fee information to help improve Blue Book in future enhancements. If left unchecked after first enabling Blue Book, you will get the following prompt:
Clicking Yes will check the box and send anonymous fee data to Open Dental.
Clicking No will keep the box unchecked, and no data will be sent.
Click OK to save changes.
Insurance Blue Book Rules Hierarchy
The Hierarchy determines the method for estimating fees for each procedure code. The hierarchy can be edited as needed, however the default Hierarchy is recommended in most cases.
Rule Type: This determines where the fee information is received from.
- *Allowed fees from received claims: This data comes from the amount entered in the Allowed column when receiving an insurance claim by procedure.
- Manual blue book fee schedule: This data comes from values manually entered into a fee schedule with a type of BlueBook. The fee schedule must be attached to the out-of-network insurance plan.
- UCR fee: This data comes from the values entered into the office UCR fee schedule.
Matching: This determines how to match the Blue Book fee to the patient.
- Insurance Plan: Match the patient by Insurance Plan
- Group Number: Match the patient by Group Number for the selected carrier.
- Insurance Carrier: Match the patient by Insurance Carrier (uses Carrier ID).
- Insurance Carrier Group: Match the patient by Insurance Carrier Group.
- All: Matches all patients by using the UCR fee.
Limit Type and Limit Value: The time frame associated with the rule. Double-click a rule to edit.
Limit Type can be in Years, Months, Days, or Weeks. Then enter the value (i.e. 1 Year, 6 Months, 30 days, etc). Select None to include the entire history.
The Hierarchy determines the method used for determining the procedure fee. Each procedure will start with the first rule listed, then work it's way down until a valid fee is available.
For example, when using the default rules:
- If there is no Manual Blue Book fee for the insurance plan, the next rule will be used, which will attempt to match by the Insurance Plan.
- If the Insurance Plan does not have a fee available, it will move to the Group Number.
- It will continue down the list until a fee is available.
- If no fees are available (e.g. brand new insurance carrier and plan), it will use the UCR fee.
Allowed Fee Logic
When pulling fees from the Allowed Amounts on a claim, Open Dental will determine if the fees should be used to calculate future estimates.
- If the allowed fee is higher than the UCR fee, Open Dental assumes it is an overpayment and will exclude it from future calculations.
- If the allowed fee is unusually higher or lower than normal (i.e. any outliers), Open Dental will exlude these from future calculations.
A history of the fee estimates for a procedure can be found in the Edit Claim Procedure window.
Downgrades: To properly calculate estimates for downgraded procedures, create a Manual Blue Book Fee Schedule for each out-of-network carrier. Only enter the allowed amounts for commonly downgraded procedure codes. Associate this fee schedule with each out-of-network carrier as needed. Also see Estimate Downgrades