Updated 12/21/2023

Now that you’ve read our post series on setting up Insurance Plans in Open Dental, it’s time to get a handle on insurance plan changes. Don’t worry, processing changes doesn’t have to be scary, and taking the right steps will prevent the horrors of accidental changes affecting all plan subscribers, duplicate plans, and changes to historical information – yikes!

In this post, we’ll cover how to handle these situations:

• The patient’s insurance has changed
• An employer has changed plans, and all subscribers need to be moved to the new plan
• The patient received care elsewhere (adjustment to benefits)
• Insurance fees have changed
• Plan benefits need to be edited/customized
• There are plan-specific downgrades
• Insurance history is needed, so frequency limitations work properly

The Patient’s Insurance has Changed

1. Drop the “Old” Plan!

Double-click to open the patient’s insurance. Use the Drop Button located at the upper left of the window to indicate this is no longer active.

Dropping an Insurance Plan removes the plan from the selected patient only. Historical information is not affected, and the plan will still exist in the Insurance Plans. The plan will no longer show in the patient’s insurance area. It will, however, still show on the family’s Insurance Plans for Family list, and you can click the Add Insurance drop-down to see it.

Some scary consequences of not using the Drop button include:

• Changes to historical information: Changing the carrier name without dropping the plan will change the carrier name in all sent claims!
• Other subscribers on the plan would be affected by any plan changes (which could cause claim denials and other ghastly problems).

2. Add the New Insurance Plan

In the Family Module, Click the Add Insurance button.

Answer the question about who the subscriber is.
Any previously used insurance plans will display. If you’re adding a new plan that’s not in the list, click “New Plan”

When the Edit Insurance Plan window pops up, click Pick From List to see if the patient’s new insurance plan may already be in your Insurance Plans list.
This helps prevent duplicate plans from being created.

An employer has changed plans, and ALL subscribers need to be moved to the new plan

When an employer switches plans, and all subscribers need to be moved, it can be time-consuming to process the changes individually.
Go to Setup> Misc Tools> Move Subscribers to move all subscribers at once.

Follow the steps shown on our Move Subscribers manual page to use this tool.

The Patient Received Care Elsewhere
(referred out procedures, etc.)

1. In the Family Module, double-click to open the patient’s insurance.
2. In the upper right next to Adjustments to Insurance Benefits, click Add.
3. Enter the amount of insurance benefits used (or deductible used) along with the date used, and click OK.

TECH TIP:
If a patient has more benefits than expected (like roll-over benefits), use a negative number to add available benefit dollars.
If a patient has used benefits elsewhere (which reduced their available benefit dollars), use a positive number.

Insurance Fees Have Changed

• Go to Lists> Procedure Codes
• Use the dropdown or […] button to select a fee schedule to display in the Fee 1 column.
• Enter new fees – the information is saved automatically. Click Close when done.

Plan Benefits Need to be Edited/Customized

The insurance plan may have different coverage for each family member.
It may exclude certain procedures.
It may cover a specific procedure at a different percentage.
A certain procedure category may not apply to the annual max.
All of these exclusions/exceptions/special conditions are referred to as Other Benefits in Open Dental.

Go to the patient’s Family Module, double-click to open the insurance plan, then double-click into Benefit Information. In Other Benefits, click +Add to create Other Benefits.

Only certain Other Benefit scenarios are functional. Visit our Other Benefits manual page for further information and detailed instructions.

There are Plan-Specific Downgrades

Global downgrades set in Lists> Procedure Codes> in the Ins. Subst Code apply to ALL procedures in the system. Some downgrades are already set by default (see the list on our Downgrades manual page).
If your insurance plan has downgrades that are different than, or in addition to, these downgrades, you can customize them inside the plan.

Double-click to open your patient’s insurance plan, then select the Other Ins Info tab.
Make sure Don’t Substitute Codes is NOT checked.
Click on the Subst Codes button to open the dialog box. Existing (global) substitution codes will display. Edit them if different for this plan.
Use the + to add any custom substitutions for this plan.

Find more on our Substitution Codes manual page.

Insurance History Entries are Needed, so Frequency Limitations Work Properly

Insurance history allows you to record any previous treatment dates for procedures completed outside your practice, so Open Dental can calculate frequency limitations accurately.

Double-click to open the patient’s insurance, then click on the Hist button.
In the Insurance History box, enter any previous treatment dates for the items shown.

More detail on this can be found on our Insurance History manual page.

TECH TIP:
Entering a date in Insurance History automatically creates an Existing Other procedure. However, creating an Existing Other procedure does not update Insurance History.

Insurance issues can seem mysterious and cause frustration. Please reach out if you need help wrangling any insurance monstrosities – we’ll take care of them and get you back in control.

Information in this post reflects features available in Open Dental Version 23.3. For the most up-to-date information, please visit our manual.