Here’s How to Fix It

When it comes to revenue cycle management in a dental office, there’s one area that gets overlooked far too often: insurance category setup and benefit verification in Open Dental.

This isn’t just about data entry. It’s about creating a system that supports accurate insurance estimates, improves patient trust, and eliminates costly billing errors. And if you’re still relying on outdated or default settings in Open Dental, you could be working harder and collecting less.

The Problem: Hidden Inefficiencies in Open Dental

Over and over, we work with offices who think their insurance setup is “fine”—until we dig in.

🔍 Duplicate insurance plans
🔍 Miscategorized procedure codes
🔍 Missing or vague coverage spans
🔍 Incorrect coordination of benefits (COB) settings
🔍 Downgrade rules that don’t match real-world claims

The result?

• Overestimates that leave patients surprised by their bills

• Underestimates that kill your collections

• An admin team drowning in claim corrections and appeals

The Fix: A Smarter Insurance Category System

Here’s a simple process (straight from our No Codes RCM Blueprint) to start optimizing how your office uses insurance categories and coverage in Open Dental:

Step 1: Run a Procedure Report

Start by identifying your most frequently billed codes over the past year.
→ Go to Reports > Procedures > Last 365 Days
→ Group by Procedure to see trends

Then flag the most commonly used “unusual” codes—like bone grafts, occlusal guards, or scaling and root planing—that often fall through the cracks of general categories.

Step 2: Create Custom Insurance Categories

Navigate to: → Setup > Family/Insurance > Insurance Categories

From here, create categories that reflect real-world usage in your office. Don’t just use the defaults. Add:

• Gingivitis Cleanings

• Core Buildups

• Nitrous

• Occlusal Guards

Each category should reflect unique coverage policies and default to 0% until customized.

Step 3: Add Coverage Spans

For each category: → Click Add Span
→ Define the relevant procedure code range (From/To)

This improves estimate accuracy and ensures consistency across treatment plans and claims.

Don’t Skip This: Denial Tracking & Downgrades

Your insurance setup should also account for common denial reasons like:

• Crowns paying on seat date vs prep date

• Waiting periods

• Frequency limits

• Missing tooth clauses

• Downgrades (e.g., composite to amalgam)

Document these and add downgrade rules in the Other Ins Info > Subst Codes section of Open Dental. It’s extra work up front, but trust us—this is what separates the practices with airtight systems from the ones stuck chasing unpaid claims.

Coordination of Benefits (COB): Are You Using the Right Rule?

Open Dental supports three COB types:

1. Standard – Secondary pays after primary (up to allowed fee)

2. Basic – Pays the difference between allowed and what primary paid

3. Carve Out – No secondary payment if primary has already paid

Setting the wrong one? You’re looking at major write-offs and wasted hours reconciling accounts.

Bonus: Use Our Insurance Verification Worksheet

We’ve built a customizable worksheet (grab it in our No Codes RCM Blueprint) to help teams verify: ✅ Patient + subscriber info
✅ Group numbers + ID accuracy
✅ Frequencies, waiting periods, and maxes
✅ Ortho benefits and downgrade policies

When used correctly, it becomes your team’s standard playbook for clean, consistent insurance entries.

Final Thoughts: It's Time to Get Proactive

If you're entering insurance plans on the fly, trusting defaults, or skipping downgrade rules altogether... you're leaving money on the table and setting your team up for frustration.

Want help making sure your Open Dental setup is optimized for accuracy, speed, and profit?

📘 Grab a copy of  Dental Revenue Cycle  Blueprint or book a consult—we’ll help you clean up your insurance protocols and create systems your team will actually use.