How to Set Up Capitation Plans in Open Dental

Managing a capitation plan is confusing because it operates differently than standard fee-for-service insurance, often leading to incorrect patient copays or missing provider production data. If your open dental capitation plan setup is not configured correctly, the software will attempt to bill the insurance company for procedures that should be covered by the monthly capitation payment, resulting in rejected claims and frustrated patients.

Before You Start

Before configuring the plan, ensure you have already created the insurance carrier in the Definitions or via the Family Module. You should also have the specific fee schedule for the capitation plan ready, as you will need to import or manually enter the allowed copay amounts for each procedure code. Ensure you are running version 25.2 or higher to utilize the most current insurance plan features.

Step-by-Step Instructions

Follow these steps to correctly configure a capitation plan for a patient:

1. Open the Family Module: Select the patient who has the capitation insurance.
2. Access Insurance Plan: Double-click on the insurance plan listed in the "Insurance" section of the Family Module to open the Edit Insurance Plan window.
3. Set Plan Type: In the Edit Insurance Plan window, locate the "Plan Type" dropdown menu and select "Capitation."
4. Assign Fee Schedule: Click the "Fee Schedule" button. In the window that opens, select the specific fee schedule that contains the patient's copay amounts for this plan. Click "OK" to save.
5. Configure Benefits: Click the "Benefits" button. Ensure the "Annual Max" and "Deductible" fields are set to zero, as these typically do not apply to capitation plans.
6. Verify Copay Settings: Go to the Account Module. When you add a procedure to the patient's chart, Open Dental will now automatically reference the assigned fee schedule to calculate the patient's copay instead of the standard office fee.
7. Finalize: Click "OK" in all open windows to save your changes.

Common Mistakes

The most frequent error is failing to assign the correct fee schedule to the plan. If you leave the fee schedule blank, the system will default to your standard office fees, causing the patient to be charged the full amount instead of the negotiated copay. Another common mistake is forgetting to set the "Plan Type" to "Capitation." If this is left as "Standard," the system will prompt you to create a "New Claim" button entry in the Account Module, which is unnecessary for capitation plans and will clutter your reports.

Related Scenarios

If you need to manage standard insurance plans alongside your capitation plans, ensure your fee schedules are clearly labeled to avoid confusion.

If you find that your monthly capitation payments are not being recorded correctly, you may need to adjust how you post these as "Other" payments in the system.

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

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