Setting Up Medical Insurance Billing in Open Dental

You are ready to submit a procedure to a patient’s medical insurance, but the claim keeps getting rejected because it looks like a standard dental claim. Mastering open dental medical insurance billing is essential because medical carriers require specific diagnosis codes (ICD-10) and different claim forms (CMS-1500) than standard dental plans. If these are not configured correctly, you will face constant denials and delayed payments.

Before You Start

Before you attempt to bill medical insurance, ensure the following prerequisites are met in your Open Dental version 25.2 or 25.3 environment:

1. Insurance Plan Setup: In the Family Module, ensure the medical insurance carrier is added as a separate insurance plan. Do not mix it with the dental plan.
2. Carrier Settings: In the Insurance Plan window, ensure the "Electronic ID" is set correctly for your medical clearinghouse and the "Claim Form" is set to "CMS-1500."
3. Diagnosis Codes: Ensure you have added the necessary ICD-10 diagnosis codes to the patient's Chart Module. Medical claims will be rejected immediately without valid diagnosis codes attached to the procedures.
4. Clearinghouse: Verify that your clearinghouse is configured to accept medical claims. Some clearinghouses require a separate enrollment for medical billing.

Step-by-Step Instructions

Follow these steps to generate and submit a medical claim:

1. Navigate to the Account Module: Select the patient and locate the procedure you intend to bill to medical insurance.
2. Create the Claim: Highlight the procedure(s), click the "New Claim" button, and select "Medical" (or the specific medical plan you created) from the list.
3. Configure the Edit Claim Window: The "Edit Claim window" will open. Verify the "Claim Type" is set to "Medical."
4. Add Diagnosis Codes: Click on the "Other Ins Info tab" within the Edit Claim window. Ensure the correct ICD-10 codes are linked to the procedures. If they are missing, you must add them to the procedure in the Chart Module first.
5. Review Claim Details: Ensure the "Status" is set to "Waiting to Send."
6. Submit the Claim: Go to the Manage Module > Send Claims. Select your medical clearinghouse from the list, ensure the claim is checked, and click "Send."
7. Update Status: Once sent, the claim status will automatically update to "Sent."

Common Mistakes

• Forgetting ICD-10 Codes: If you submit a claim without linking diagnosis codes, the medical carrier will reject it as "incomplete." Always verify the "Other Ins Info tab" before clicking send.
• Mixing Dental and Medical Procedures: If you include dental procedures on a CMS-1500 form, the claim will be denied. Use the "Split Claim" button in the Edit Claim window to separate dental and medical procedures if they were accidentally grouped together.
• Incorrect Claim Form: If you leave the claim form set to "ADA Dental Claim Form" instead of "CMS-1500," the medical carrier will not be able to process the document.

Related Scenarios

• If you need to track claims that haven't been paid, use the .
• If you are struggling with claims that were never sent, check the .

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.