Insurance Plans  

Every insurance plan has one subscriber and can be attached to multiple patients, but a plan is never shared between subscribers. This ensures that you will not accidently change plan info on someone else's plan. Insurance plans are accessed from the Family module of a patient.

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. This plan will still be a unique plan in the database, but it will be identical in many ways to the other plan. To keep then syncronized, you would need to make sure the box at the bottom is checked to 'Apply changes to all identical insurance plans". To set this checkbox to always be checked for all plans, go to Setup Misc, and check the box that says ' Many patients have identical insurance plans...'

The identical plans box shows the number of identical plans as well as the names of the subscribers for those plans. If you change any information for the insurance plan without checking the box at the bottom to apply to all, then this plan will no longer be identical to those listed and the list may not be there when you open this window back up. No information gets synchronized unless you purposely use this checkbox. The reason is that it is very important to not have to worry about accidently changing someone else's insurance.

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 Easy Options.

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.

Apply deductible before percentage. See the Deductible Calculation page for an explanation. There is also a global default setting in Setup Misc.

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.

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 is are also two other types of fee schedules: co-pay and allowed. When setting up fee schedules in the Definitions section, each fee schedule can be set to one of the three types. Only the fee schedules of that type will show in the appropriate list. The regular fee schedule was described above. The other two are described here.

The co-pay fee schedule is optional and is not used very much. If you set up a co-pay fee schedule, then any amounts in that fee schedule will override the patient portion for that procedure. The co-pay fee schedule might be used for certain types of PPO plans where you know exactly what the patient portion will be. For instance, your carrier might specify that a $10 copay was required for certain preventive procedures. You could set up a fee schedule with $10 for certain procedures and leave the others blank. Most procedures would then be calculated acording to the percentages, or at 100% if flat co-pay was selected. But the procedures with the $10 copays would override the usual calculation method. Again, you should see the section on Types of Insurance Plans for more specific examples.

Carrier allowed amount fee schedule should be used rarely until this feature is improved. The intent was to handle situations where insurance companies do not allow the full fee because they claim it is above UCR for the area. That allowed fee is then tracked in an allowed fee schedule attached to the plan. The allowed amounts are entered as insurance payments come in at the top of the Claim Proc window. This allowed fee will then be used for all calculations instead of the regular Fee. While it is functional, it is also time consuming and requires a lot of user involvement. The user would have to set up a special fee schedule with a name similar to the plan. Everyone would then have to remember to attach this fee schedule to all future similar plans. They would also have to click the Update button in the claim proc window as the payment came in. The whole process needs to be streamlined and completely automated. In the meantime, it is still useful if you have a large number of patients on one plan.

Request Benefits
This only applies if you are using Trojan or Insurance Answers Plus. It will later be extended to use electronic benefit requests from insurance companies.

Benefit Information

See Benefit Information.