Also known as mixed capitation, this Insurance Plan Type is used for HMOs or DMOs with supplemental payments and co-pays.
It tracks write-offs and is common in Texas (e.g. CHIP, MCNA, DentaQuest, Medicaid).
Create a PPO plan that tracks write-offs, then add a co-pay fee schedule.
- Create a normal Fee Schedule for the carrier. To calculate the fee for each procedure, add the insurance supplemental amount to the patient co-pay. ("Insurance Supplemental Amounts + Patient Co-Pay = Procedure Fee").
- Create a co-pay fee schedule for the carrier, then for each procedure enter the patient co-pay.
Note: If there is no fee, make sure to enter 0 or the patient will get charged the UCR fees (or set the blank entry default behavior in Family Module Preferences
- On the Insurance Plan, set the following:
- Plan Type: PPO Percentage
- Fee Schedule: The carrier's normal fee schedule.
- Patient Co-Pay Amounts: The carrier's co-pay fee schedule.
- Benefit Information: Set benefits to 100% for all categories.
Example: For Procedure A, DMO Insurance's will pay $90 and the patient has a co-pay of $10.
- In the normal fee schedule, Procedure A will have a fee amount of $100 (insurance + co-pay).
- In the co-pay fee schedule, Procedure A will have a fee of $10 (the co-pay).
To calculate insurance estimates, Open Dental uses the following equation:
Procedure A normal fee ($100) - Procedure A co-pay fee ($10) = Insurance estimate ($90)
If you entered this kind of plan as a Capitation plan type with a co-pay fee schedule, follow these steps to fix it.
- In the Main Menu, click Setup, Fee Schedules. Add a normal fee schedule with a similar but not identical name to the existing co-pay fee schedule.
- For each procedure in the normal fee schedule, enter the fees using the following equation to determine the amount:
(Patient Co-Pay + Insurance Supplemental Amounts = Procedure Fee)
Make sure to enter 0 for all fees where there is no supplemental fee or co-pay.
- On the Edit Insurance plan window, change the following:
- Plan Type: PPO Percentage (from Capitation).
- Fee Schedule: The new normal fee schedule.
- Benefit Information: Set benefits to 100% for all benefit categories.
For tips on setting up your co-pay fee schedules, see Fee Schedule Logic.