Open Dental Software - Frequency Limitations

Frequency Limitations

Insurance frequency limitations may or may not affect estimates of treatment planned procedures, depending on preferences.

In the Edit Benefits window, at the left, is the Frequencies section.

When insurance frequency checking is enabled:

In the Treatment Plan Module, primary and secondary insurance estimates will consider frequency limitations.
When checking for frequencies, tooth number, surface, and tooth range is taken into consideration.
(e.g. If insurance covers one composite filling per year, per tooth - Open Dental can't calculate this as we treat composite fillings per surface, not per tooth.)
When scheduling a procedure that has met its limitation, a warning will pop up.

Set up and Enable Frequency Checking

Frequency checking is enabled by default. If it needs to be re-enabled, in Preferences, check Enable Insurance Frequency Checking and verify the codes affected by each limitation. Default codes are already included, and new codes can be added as needed. It is not recommended to change or remove default codes as it can affect estimates or benefits.

Benefit Frequencies

Example 1: Frequency Limitation met due to completed procedures.

Enter the plan's frequency limitations in the Edit Benefits window. Click More to add additional frequency limitations.

To enter a benefit frequency, choose the frequency type from the drop down and enter the corresponding number in the # box.

Any frequency limitations only shown after clicking More (e.g., Crowns, SRP, etc), will also be added to the Other Benefits grid, using the first procedure code in the Frequency Checking list for the specified category. The frequency limitation will still be functional for all codes in the Frequency Checking list set up in Preferences.

For each frequency limitation type added, a row will show in the Family Module, Insurance Plan area.

For additional options for frequency limitations (e.g., override frequency for a specific patient), see Other Benefits.

View Estimates for Treatment Planned Procedures

In the Treatment Plan Module, click the Estimates as of dropdown and select the date. Once a date is selected, treatment plan estimates will be updated to reflect the chosen date.

When a procedure is not covered due to a frequency limitation, the procedure's description will indicate this.

Note: For completed procedures to affect frequency limitations in the treatment plan, the completed procedure must be attached to an insurance claim for the same insurance plan. Procedures will affect frequency once attached to a claim. Once claims are received, denied procedures or procedures that insurance pays $0 will still be counted toward the frequency. Dates entered into Insurance History will also be considered.

Example

Frequency limitation for BWs is every 2 years. On 12/28/2019, patient had BWs taken and a claim was sent.

In the Edit Benefits window, enter the frequency limitation as shown below:

In the Treatment Plan Module:

When the Estimates as of date is 12/29/2021 and later (2 years after completed procedure), BW estimates will indicate it is covered.
When the Estimates as of date is 12/28/2021 or earlier (limitation already met), the BW estimate will indicate that the procedure is not covered by insurance.

When scheduling an appointment:

If the schedule date is 12/29/2021 or later, scheduling proceeds as normal.
If the schedule date is 12/28/2021 or earlier, a warning will pop up indicating a frequency conflict exists. User has the option to proceed or cancel.

Example 2: Frequency Limitation met due to treatment planned procedures

Frequency limitation for Pano/FMX is once every 5 years. The patient last had a Pano on 9/2/2017 and it is currently 9/6/2022, so they are due for a new Pano/FMX. both the D0330 (Pano) and D0210 (FMX) are treatment planned.

The FMX will be marked as a frequency limitation since the patient only gets one every 5 years and the Pano comes first in the treatment plan.