Insurance Blue Book Setup

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.

Workflow:

  1. Users set up Blue Book in this window to determine the best method for estimating procedure fees.
  2. As claims are received, users enter the allowed fee from the EOB into the claim.
  3. 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. See below for details.

Blue Book Settings: These settings pertain to the Blue Book feature (does not affect Legacy).

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.

Matching: This determines how to match the Blue Book fee to the patient.

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.

Hierarchy Logic

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:

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.

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.

Blue Book vs Legacy Blue Book

Blue Book: This is the recommended method.

When Blue Book is enabled, all out-of-network plans (Category Percentage) will use Blue Book for determining the procedure's insurance estimate.

If insurance provides a fee schedule with allowed amounts, enter them as a Manual Blue Book Fee Schedule. Associate this fee schedule to the insurance plan.

If insurance does not provide a fee schedule, allowed amounts can typically be found on EOB's as claims are sent and received. When Receiving a Claim, enter the Allowed amount. This will update the Blue Book so that future patients will have more accurate estimates.

Note:
  • Category Percentage plans that have a fee schedule associated (in the Fee Schedule box directly under the Plan Type) will not begin using Blue Book until the fee schedule is removed.
  • Only payments from primary carriers are considered in blue book log estimates.

Legacy Blue Book

When Legacy Blue Book is enabled, out-of-network (Category Percentage) plans will have a fee schedule automatically created and attached based on the insurance carrier.

The new out-of-network fee schedule is automatically created and attached to the insurance plan. When claims are received, the allowed amounts will be entered onto the carrier fee schedule.

Legacy Blue Book can make fee schedules difficult to manage, especially if there are many duplicate carriers. Since fee schedules are named by carrier, it can be hard to determine which fee schedule to review when needed.

Note: If you are moving from Legacy Blue Book to Blue Book:
  • If you have entered fees into an Out-of-Network fee schedule, they will need to be copied to Manual Blue Book fee schedules. See Fees Copy. Then associate the fee schedule to the insurance plan.
  • If you have entered allowed amounts into the Allowed column on claims in the past, these amounts will be considered for future calculations.