Setting Up Open Dental Frequency Limitations

You have just performed a routine cleaning, but when you go to bill the insurance, the claim is denied because the patient already had a cleaning at another office six months ago. Manually tracking these rules is a nightmare, but configuring open dental frequency limitations directly in the software ensures the system warns you before you submit a claim that is destined to be rejected.

Before You Start

Before you can set up frequency rules, ensure you have the following completed:

1. The patient’s insurance plan must be correctly entered in the Family Module.
2. You should have the patient's EOB or benefit breakdown handy to know exactly what the frequency rules are (e.g., "two cleanings per rolling 12 months" or "two exams per calendar year").
3. You must have the appropriate security permissions to edit insurance plans. If you are unsure, check with your office administrator.

Step-by-Step Instructions

Follow these steps to apply frequency rules to a specific insurance plan:

1. Go to the Family Module.
2. Double-click on the patient's insurance plan to open the Edit Insurance Plan window.
3. Click the Benefits/Coverages button. This opens the Benefits window.
4. Click the Add button to create a new benefit entry.
5. In the Category dropdown, select the category that matches the procedure (e.g., "Diagnostic" for exams or "Preventive" for cleanings).
6. In the Benefit Type dropdown, select "Frequency."
7. In the Quantity field, enter the number of times the procedure is allowed (e.g., "2").
8. In the Time Period dropdown, select the appropriate interval (e.g., "Calendar Year," "Rolling 12 Months," or "Service Year").
9. Click OK to save the benefit.
10. Click OK again to close the Edit Insurance Plan window.

Once saved, when you attempt to attach a procedure to a claim in the Account Module that exceeds these limits, Open Dental will display a warning, allowing you to address the issue before the claim is sent.

Common Mistakes

• Confusing Calendar Year with Rolling 12 Months: If you select "Calendar Year" when the policy actually uses "Rolling 12 Months," the system will not trigger the warning correctly, leading to unexpected claim denials. Always verify the specific language in the patient's benefit summary.
• Applying to the Wrong Category: If you apply a frequency limit to the "General" category instead of the specific "Preventive" category, the system may block procedures that should be covered, or fail to block those that should be limited.
• Forgetting to Update the Plan: If you edit the benefits for one patient but do not update the plan for other family members on the same policy, you will continue to see inconsistent warnings across the family account.

Related Scenarios

If you need to verify if a procedure has already been billed to insurance, you can run the . If you are dealing with a claim that was denied due to frequency, you may need to learn .

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.