How to Set Up Medical Insurance Billing

You are trying to submit a procedure to a patient's medical insurance, but the claim keeps getting rejected or sent to the dental carrier instead. Mastering open dental medical insurance billing is often confusing because the software defaults to dental settings, requiring specific adjustments to the insurance plan and claim form to ensure the medical carrier accepts the electronic submission.

Before You Start

Before attempting to submit a medical claim, ensure the following prerequisites are met in your version 25.3 environment:

1. Medical Carrier Setup: In the Family Module, ensure the patient has a medical insurance plan added. In the Edit Insurance Plan window, verify the "Carrier" is set to the medical insurance company and the "Electronic ID" is correct for medical claims (this may differ from their dental ID).
2. Claim Form Selection: Ensure you have a medical claim form (such as the CMS-1500) selected in the Edit Insurance Plan window under the "Claim Form" dropdown.
3. Clearinghouse Configuration: Verify in Setup > Family/Insurance > Clearinghouses that your clearinghouse is configured to accept medical claims. Some clearinghouses require a separate enrollment for medical billing.
4. Procedure Codes: Ensure the procedures you intend to bill have the correct medical codes (CPT/HCPCS) associated with them in the Procedure Code Editor.

Step-by-Step Instructions

Follow these steps to create and submit a medical claim:

1. Account Module: Select the patient and locate the procedures you wish to bill.
2. Create the Claim: Click the New Claim button. In the Edit Claim window, ensure the "Insurance Plan" dropdown is set to the medical insurance plan you created.
3. Verify Information: In the Edit Claim window, check the "Other Ins Info" tab to ensure all required medical fields (such as referring provider NPI and diagnosis codes) are populated.
4. Status: Ensure the claim status is set to "Waiting to Send."
5. Save: Click "OK" to save the claim.
6. Send the Claim: Go to the Manage Module and click the Send Claims button. Select your medical clearinghouse from the list and click "Send" to transmit the claim electronically.

Common Mistakes

• Using Dental Codes: If you bill a procedure using a CDT code (e.g., D0150) instead of the required CPT/HCPCS code, the medical carrier will automatically reject the claim. Always verify the code mapping in the Procedure Code Editor.
• Incorrect Claim Form: If you leave the claim form set to the standard dental "ADA 2019" form instead of the "CMS-1500," the medical clearinghouse will not be able to process the data correctly.
• Missing Diagnosis Codes: Medical claims require ICD-10 diagnosis codes. If you do not enter these in the Edit Claim window, the claim will be denied for lack of medical necessity.

Related Scenarios

• If you need to bill a portion of a procedure to dental and a portion to medical, use the Split Claim button in the Edit Claim window to separate the charges.
• When receiving payment, always use the By Procedure button to ensure the payment is applied correctly to the specific medical procedure, especially if the medical carrier pays differently than dental.

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.