Estimate Downgrades

In an Insurance Plan, on the Other Ins Info Tab, is a button for Subst Codes.

See our QuickTip video on Customizing Downgrade Codes for an Insurance Plan.

Sometimes an Insurance Plan will reduce payment for a procedure based on material (e.g. composite to amalgam or porcelain to gold). To account for downgrades in payment for certain procedures, Open Dental can automatically calculate downgraded estimates.

In Open Dental, downgraded estimates are based on insurance substitution codes and whether or not the insurance plan is set up to apply substitution codes.

  • The substitution code fee is never more expensive than the original procedure code fee.
  • Downgrades can include or exclude write-offs depending on your insurance setup.
  • To see an example of the math behind downgrades, see PPO Insurance Calculations.

Downgrade Estimates for an Insurance Plan

When an insurance plan is set to downgrade estimates:

Set a Downgrade Universally for all Insurance Plans

For procedures commonly downgraded by most insurances, users can create codes that default to downgrades for all insurance plans.

By default, Open Dental associates four composite procedure codes with corresponding amalgam substitution codes.

To create additional universally downgraded codes:

In the Main Menu, click Lists, Procedure Codes.

Make sure the correct fees are entered in the fee schedule for both the procedure code to be completed and the substitution code.

Double-click the procedure code to be completed.

In the Ins. Subst Code field enter the insurance substitution code. In the above example, composite code D2391 has an amalgam substitution code of D2140.

Optionally set the Only if condition.

Set a Downgrade on the Insurance Plan Level

By default, insurance plans are set to apply downgrades for all procedure codes with substitution codes (Don't Substitute Codes is unchecked). Optionally, insurance plans can have specific downgrades set, or universal downgrades can be excluded.

Open the Insurance Plan, Other Ins Info Tab.

Make sure the option Don't Substitute Codes is unchecked. This is unchecked by default and determines whether the plan calculates downgrades. This will affect all procedures with substitution codes, unless you specify which codes to include/exclude.

Select whether or not to calculate write-offs by checking or unchecking PPO substitution calculates writeoffs. The write-off is calculated using the office fee and and the fee for the originally charted procedure.

To control which procedure codes are downgraded for this plan, click Subst Codes.

Click + to add a new substitution code.

Do not Downgrade Estimates for an Insurance Plan

To turn off downgraded estimates for a plan, on the Edit Insurance Plan window, Other Ins Info tab, check Don't Substitute Codes. All estimates for the plan will be based on the procedure to be completed and substitution codes will be ignored.

When an insurance plan is set to not downgrade estimates:

To exclude a specific procedure code from being downgraded, change the SubstOnlyIf column to Never.