How to Set Up Capitation Plans in Open Dental

Managing a capitation plan is confusing because it flips the standard fee-for-service model on its head, often leading to incorrect patient co-pays or missed revenue tracking. When you fail to configure the plan correctly, the system may attempt to bill insurance for procedures that should be covered by the monthly capitation payment, resulting in rejected claims and frustrated patients.

Before You Start

Before beginning your open dental capitation plan setup, ensure you have the following completed:

1. Insurance Carrier Created: Go to Lists > Insurance Carriers and ensure the capitation carrier is already in your system.
2. Fee Schedule Created: You must have a specific fee schedule that lists the patient co-pay amounts for this plan. Go to Lists > Fee Schedules to create or import this.
3. Provider Setup: Ensure the providers who will be performing the work are correctly set up in Setup > Providers.

Step-by-Step Instructions

Follow these steps to configure the plan correctly in the Family Module.

1. Open the Family Module: Select the patient who is covered by the capitation plan.
2. Access Insurance Plan: Double-click the insurance plan listed in the "Insurance" grid 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 dropdown and select the specific co-pay fee schedule you created for this plan. This ensures that when you chart procedures, the patient's portion automatically defaults to the correct co-pay amount.
5. Configure Benefits: Click the Benefits button. For capitation plans, you typically do not enter standard annual maximums or deductibles. Instead, ensure the Plan Type is correctly reflected here. Click OK to save.
6. Verify Coverage: In the Edit Insurance Plan window, click OK to save your changes.
7. Apply to Patient: In the Family Module, ensure this plan is attached to the patient's record. If the patient has secondary insurance, ensure the capitation plan is set as the primary.

Common Mistakes

• Forgetting to set the Plan Type: If you leave the plan type as "Standard" instead of "Capitation," Open Dental will attempt to generate insurance claims for procedures that should be covered by the capitation agreement. This leads to unnecessary claim rejections.
• Incorrect Fee Schedule Association: If you associate the wrong fee schedule, the patient's co-pay will be calculated incorrectly at the time of checkout. Always verify the co-pay amounts in the Account Module before finalizing the patient's payment.
• Billing Insurance for Capitated Procedures: Manually creating a "New Claim" for a procedure covered under a capitation plan will cause confusion in your Outstanding Insurance Claims Report. Only bill insurance for procedures specifically excluded from the capitation agreement.

Related Scenarios

• If you need to manage standard insurance plans, see .
• For tracking payments received from insurance carriers, see .

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.