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Medical Insurance

Open Dental has good support for medical insurance making it useful in oral surgery and hospital settings. Below is information about how to use Open Dental's medical insurance features. 

Turn on Medical Features:  In the Main Menu, click Setup, Advanced Setup, Show Features, then select Medical Insurance.  Restart Open Dental for the change to take effect.

Insurance Plans
Patients can have unlimited insurance plans.  To designate an insurance plan as medical, select the following on the Edit Insurance Plan window.

  • Check the Medical Insurance box. This will identify the plan as medical instead of dental. 
  • Select the claim form for the plan. 
    • HCFA 1500/ CMS 1500:  If printed, must use preprinted forms due to its red background.  They do not allow printing the background from a printer.
      The new 1500 Health Insurance Claim Form (version 02/12) is included in version 14.2 and named named '1500_02_2012'. '1500' is the old version of the form.  To reassign the new 1500_02_2012 claim form to insurance plans currently using the old 1500, see Claim Forms, Reassigning Claim Forms. 
    • UB04: Typically used for institutional claims and is included in Version 12.0.  They are printed on preprinted forms, not sent in e-claims. When viewing onscreen or changing layout, it may be helpful to have the background image on the claim form.  To add the background image, save the file UB04.jpg in your A to Z folder, then add the image to the UB04 in Claim Form Setup.  Make sure the image is set to not print.

Medical Procedure Codes
Add medical codes (e.g. CPT Codes) as separate codes in the procedure code list. See Add Procedure Codes.  We recommend creating a Medical Code category in Definitions, Proc Code Categories and assigning medical codes to it. 

Cross code medical codes to procedure codes (also see Cross Coding Procedure Codes to Medical Codes)

  1. Create the medical procedure code using a CPT code instead of a dental code.  Leave the Medical Code field blank.
  2. For the dental procedure code, enter the medical procedure code (CPT code) in the Medical Code field. See Edit Procedure Codes.

Cross coding only affects medical claims.  It does not affect what shows on Continuity of Care documents (CCDs)

Medical information can also be entered on the Procedure Edit window, Medical tab.

  • Medical Code: This box is filled in automatically when the procedure code is cross coded to a medical code.
  • ICD Diagnosis Codes: Multiple ICD-10 codes can be used in conjunction with procedure codes. When attached to a procedure, one procedure for each visit needs to have Principal Diagnosis checked. Note: To update to ICD-10 codes, see ICD Diagnosis Codes

Create medical claims in the Account module. See Claim Types for details on how insurance setup affects claim type.

  • Select the procedures, then click the New Claim dropdown, Medical. 
  • If procedure codes are cross coded to medical codes, the medical codes will be sent.
  • Change the Med/Dent or Claim Form settings on the Edit Claim window.

Use Emdeon Medical to process medical claims.

  • Medical vs Institutional: There are two formats for medical e-claims: medical (837-P) or institutional (837-I). The default is medical.  To change, see Account Module Preferences, 'Set medical claims to institutional when using medical insurance'.  The type can also be changed on individual claims (Edit Claim window, Med/Dent).
  • Clearinghouse:  Set the default medical/institutional Clearinghouse (separate from the dental default).  Dental clearinghouses cannot accept medical or institutional claims.  If you will generate claim files from Open Dental and upload them manually to Medicaid, you still need to set up a clearinghouse to specify the Claim Export Path. Medical and institutional claim format will be only 5010.  Dental claim format can be 4010 or 5010 and you can freely switch as needed. 
  • Send Claims:  Send batches of claims to one clearinghouse at once. Send Batch Claims.
    [Technical note: To determine the format, information is required from both the claim.MedType and the clearinghouse.Eformat. Neither alone is sufficient.]
    Once messages are generated, they are archived in the etrans table in the database for later retrieval. These archived claims may be seen in the history list at the bottom of the Insurance Claims window.   All 4 claim types (med5010, inst5010, dent5010, dent4010) will show as "claim sent" in the archival.


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