When an insurance carrier pays for a less expensive procedure than the one actually performed, you are dealing with an open dental insurance downgrade. If you do not adjust the claim and the patient’s estimated portion correctly, your Account Module will show an incorrect balance, leading to frustrated patients and inaccurate aging reports.
Before You Start
Before processing a downgrade, ensure your insurance plan is correctly set up in the Family Module. You must have the specific insurance plan selected and the "Insurance Plan" window open to verify that the "Downgrade" or "Alternative Benefit" logic is understood for that carrier. Additionally, ensure you have the EOB or ERA in front of you, as you will need the specific allowed amount and the carrier's reason code for the downgrade.
Step-by-Step Instructions
Follow these steps in the Account Module to handle a downgrade accurately:
- Locate the Claim: In the Account Module, find the claim that was paid with a downgrade. Double-click the claim to open the "Edit Claim" window.
- Receive the Payment: Click the "Receive Payment" button. In the "Enter Payment" window, select the "By Procedure" button.
- Adjust the Estimate: Locate the procedure that was downgraded. In the "Ins Pay" column, enter the amount the insurance actually paid. In the "Write-off" column, enter the difference between the original fee and the insurance's allowed amount for the downgraded procedure.
- Update the Claim Status: Ensure the status is set to "Received." If there are remaining procedures on the claim that were not paid, you may need to use the "Split Claim" button if you intend to send the remaining items to a secondary carrier.
- Finalize: Click "OK" to save the payment. The Account Module will now reflect the patient's remaining responsibility based on the adjusted estimate.
Common Mistakes
The most frequent error is failing to enter the write-off amount during the payment entry process. If you only enter the insurance payment amount without accounting for the write-off, the patient's balance will appear artificially high, leading to incorrect billing statements. Another common mistake is forgetting to use the "Split Claim" button when a downgrade only applies to one procedure on a multi-procedure claim; this prevents you from correctly billing the secondary insurance for the remaining balance of the non-downgraded procedures.
Related Scenarios
If you need to track these adjustments over time, will help you identify claims that have not been fully resolved. If you are dealing with secondary insurance, provides guidance on handling claims after the primary has 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.