Setup Insurance Categories

In the Main Menu, select Setup | Insurance Categories. The purpose of these categories is to allow automatic insurance coverage calculations based on the procedure code.

Notice that any older categories that you had setup previously have been moved to the bottom of the list and hidden. The eleven new categories have been added to the top. Insurance plans previously entered can continue to use the old categories, while new insurance plans will use the new categories. You should not alter the new categories unless you really understand what you are doing, or you might not be able to use Benefit Info properly. If you have altered them for some reason, you should change them back as explained below.

There are really two setup functions that are performed from here and each will be addressed separately:

Coverage Categories

The categories are completely unrelated to the procedure code categories which are setup in Definitions and are just a way to group Procedure Codes for viewing purposes. Coverage categories, on the other hand, have specific spans of procedure codes attached to them according to typical insurance groupings. They are used to perform the actual calculations of insurance coverage for specific procedures. To edit a coverage category, double click on a gray row in the list. To add a new category, click on the Add button. In either case, the following window will open:

The default percentage is the percentage that will be filled in for new insurance plans. Changing this number does not affect any patient records, but only changes the way future insurance plans are initially filled out. The Electronic Benefit Category will be used as we move to real-time electronic benefit communications with insurance companies. It is very important that when you are done editing your categories that you have Exactly one of each E-benefit category, as shown in the screenshot at the top of this page. You cannot have any duplicates, and you cannot have any missing. The General category should be at the top, because it will be used to keep track of annual maximums for all patients.

Coverage Spans

Each coverage category can have unlimited spans of procedure codes attached to it. The included spans should work for most offices, although you can fine tune them if you desire. Adding extra spans does not increase complexity for the staff. They will still only see the categories you have set up. The 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 using the Delete button. Although this will affect patient data if the span includes a patient's procedure, it does not corrupt the data. Note that changes here will affect the treatment plans of multiple patients.

To edit a coverage span, double click on a white row in the list. Or, to add a new span, click the Add Span button to the right. In either case, the following window will open:

Open Dental warns you if the ADA code is not in the correct 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.