Handling Coordination of Benefits in Open Dental

When a patient has two insurance plans, managing the open dental coordination of benefits process is often where billing errors occur, leading to rejected secondary claims or incorrect patient balances. If you fail to link the primary payment correctly or neglect to set the secondary claim status to "Hold until Pri Received," you will likely end up with frustrated patients and unpaid claims that sit in your aging report indefinitely.

Before You Start

Before attempting to bill a secondary insurance plan, ensure the following prerequisites are met in your system:

1. Verify Insurance Plans: Ensure both the primary and secondary insurance plans are entered correctly in the Family Module. The secondary plan must be listed below the primary plan in the "Insurance Plans" section.
2. Verify Order of Benefits: Confirm that the "Order of Benefits" is set correctly for the patient. You can check this by double-clicking the insurance plan in the Family Module and ensuring the "Relationship to Subscriber" and "Coordination of Benefits" fields are accurate.
3. Clear Primary Claim: The primary claim must be marked as "Received" in the Account Module before you can accurately bill the secondary carrier.

Step-by-Step Instructions

Follow these steps to process a secondary claim after the primary insurance has paid.

1. Receive Primary Payment: Go to the Account Module. Locate the primary claim, double-click it to open the Edit Claim window, and click the "Receive Payment" button. Enter the payment details from the EOB or ERA.
2. Create Secondary Claim: In the Account Module, click the dropdown arrow next to the "New Claim" button and select "Secondary Claim."
3. Configure Secondary Claim: The Edit Claim window will open. Ensure the "Claim Type" is set to "Secondary."
4. Set Status: On the Other Ins Info tab within the Edit Claim window, verify that the "Claim Status" is set to "Waiting to Send." If you are waiting for the primary EOB to be fully processed or attached, you may set the status to "Hold until Pri Received."
5. Attach Primary EOB: If your clearinghouse requires the primary EOB for the secondary claim, use the "Attachments" section in the Edit Claim window to upload the primary EOB image.
6. Submit Claim: Once the claim is ready, click "OK" to save. When you are ready to transmit, go to the Manage Module > "Send Claims" to batch and send the secondary claim to your clearinghouse.

Common Mistakes

• Forgetting to "Hold until Pri Received": If you do not set the secondary claim to "Hold until Pri Received" while waiting for the primary payment, the claim may be sent prematurely, leading to an automatic denial from the secondary carrier.
• Incorrect Payment Allocation: If you click "Receive Payment" without selecting the "By Procedure" button, the payment might be applied to the entire claim balance rather than individual procedures. This makes it impossible to accurately track which specific procedures the secondary insurance is responsible for covering.

Related Scenarios

If you need to adjust a claim after it has already been processed, learn how to use the . If you are struggling to find missing claims, to identify which secondary claims have not yet been paid.

Track all your outstanding claims at a glance with DentalCanvas — a visual dashboard that shows your insurance aging, pending claims, and collection trends in real time.

This article is provided by opendentalsupport.com, an independent community resource. We are not affiliated with Open Dental Software, Inc.