Module 5: Insurance Setup, Estimates, and Claims

If you ask an Open Dental office manager which part of the software causes the most trouble, the answer is almost always insurance. That is not because the insurance tools are weak. It is because insurance data is layered: a carrier sits under a plan, a plan is shared by subscribers, a subscriber's coverage is attached to patients, benefits sit on the plan, and fee schedules decide the math. Get one layer wrong and every estimate, claim, and write-off downstream inherits the error.

This module follows the data in the order it flows: carrier, plan, subscriber, benefits, fee schedule, estimate, claim, response. Payment posting (receiving claims, finalizing insurance checks, and ERAs) gets its own deep treatment in Module 6, because it is really an accounts receivable skill. Here we get everything right before the check arrives, and we cover what to do when it does not.

Key takeaways

Open Dental separates the insurance plan (shared by everyone on the same employer group), the subscriber (the policyholder), and the patient's link to that coverage. Editing a shared plan changes it for every subscriber on it, including their history.
The plan type decides the math. PPO plan types track write-offs; Category Percentage does not. Choosing the wrong type is the single most common cause of bad estimates.
On a PPO plan, the billed fee comes from the provider's fee schedule and the allowed fee comes from the fee schedule on the plan. A PPO plan with no fee schedule produces estimates that look fine and are wrong.
Claims should leave the building daily. Use the Send Claims window, the Procedures Not Billed to Insurance report, and the Outstanding Insurance Claims report as a three-part safety net.
Denials are a workflow, not an event. Record the reason, fix the root cause in the plan or procedure data, send a corrected claim or appeal, and track it with custom tracking statuses until it closes.

ChairsideSource is independent and is not affiliated with or endorsed by Open Dental Software, Inc. Menu paths below were checked against the public Open Dental online manual in 2026. Open Dental changes screens between versions, so if a label on your screen differs, search the manual for the feature name and follow the version you run.

How Open Dental structures insurance data

You will make fewer mistakes if you understand the four layers before you touch a single window. In Open Dental's own terms:

Carrier. The insurance company: name, address, phone, and the electronic payer ID used for e-claims. Carriers live in Lists > Insurance Carriers.
Insurance plan. The coverage template for a group: carrier, employer, group name and number, plan type, fee schedule, and benefits. Many subscribers can share one plan. Plans live in Lists > Insurance Plans.
Subscriber. The policyholder, with a subscriber ID and effective dates. Subscriber-specific details like assignment of benefits and the subscriber note live here.
Patient plan. The link between a patient and a subscriber's coverage, with the patient's relationship to the subscriber and the order (1 for primary, 2 for secondary). Open Dental stores this in its patplan table.

Why this matters: when you open a patient's insurance in the Family module, you are looking at all four layers in one window. Some fields change only this patient's link, some change the subscriber, and some change the plan for every subscriber who shares it. If you have not read Module 2 on families and guarantors, do that first, because subscriber relationships follow the same family logic.

Layer	Where you see it	Change it and you affect
Carrier	Lists > Insurance Carriers, or the Carrier field in the plan	Every plan attached to that carrier, including claims already sent
Insurance plan	Plan Info tab of the Edit Insurance Plan window	Every subscriber on the plan, unless you create a new plan
Subscriber	Subscriber Information section	That subscriber and every dependent on their coverage
Patient plan	Patient Information section at the top of the window	This patient only

Setting up carriers and plans correctly

Carriers: one company, one record

Duplicate carriers are the first mess most offices inherit. "Delta Dental," "Delta Dental of XX," and "DELTA DENTAL PPO" typed three different ways by three different front desk hires will scatter your reporting and your payer IDs. Before adding a carrier, search for it. When duplicates already exist, use the Combine function from the Carriers list rather than deleting, because Open Dental only lets you delete carriers that are not attached to any plan or subscriber.

Go to Lists > Insurance Carriers and search by the first word of the carrier name.
Open the correct record and confirm the Electronic ID (payer ID) against your clearinghouse's payer list. A wrong payer ID means claims go nowhere or to the wrong payer.
Set Send Electronically appropriately. Some carriers accept primary e-claims but not secondary ones; the field has an option for that case.
If you use ERAs, review the carrier's ERA Automation setting, which can follow the global preference or be set per carrier.
Mark obsolete carriers Hidden so staff stop picking them.

Adding insurance to a patient

The workflow starts in the Family module, and the order matters: enter the subscriber's coverage first, then attach dependents to it.

Select the patient and click Add Insurance in the Family module toolbar.
Open Dental asks whether the patient is the subscriber. Click Yes if they are. Click No if not, then pick the subscriber from the family (or use More Patients for a subscriber outside the family).
If the subscriber already has plans, they are listed. Select one and click OK, or click New Plan.
For a new plan, use Pick from List first to see whether the employer group already exists in your database. Reusing an existing plan keeps benefits and fee schedule consistent for everyone at that employer.
Only if nothing matches, build a new plan: carrier, employer, group name, group number, plan type, fee schedule.
Enter the Subscriber ID (required) and effective date, and set Relationship to Subscriber for the patient (required).
Confirm the patient's Order: 1 for primary, 2 for secondary.

Open Dental notes that many carriers now expect each patient to be listed as their own subscriber on some plan types, and Medicaid IDs usually go in the Subscriber ID field. When a carrier's rules differ from how you entered the family, fix it at intake, not after the first rejection.

Choosing the plan type

The plan type is the most consequential field in the window, because it decides how Open Dental calculates estimates and whether it tracks write-offs. The options in the Plan Type dropdown on the Plan Info tab are:

Plan type	Use it for	Write-offs tracked?	Fee schedule on the plan
Category Percentage	Out-of-network (indemnity-style) plans paying a percentage by category	No	Optional
PPO Percentage	In-network plans that pay a percentage of a contracted fee	Yes	Required for correct estimates
PPO Fixed Benefit	In-network plans that pay a fixed dollar amount per procedure	Yes	Required, plus a fixed benefit fee schedule
Medicaid or Flat Co-pay	Plans with 100% coverage and a flat patient copay, no percentages, maximums, or deductibles	No	Copay amounts only
Capitation	HMO or DMO plans that pay the office a flat monthly amount	Yes	Copay fee schedule for patient amounts

Expensive mistake: in-network plans entered as Category Percentage. If you are contracted with a PPO but the plan is set to Category Percentage, Open Dental does not track the contractual write-off. Estimates show the patient owing far more than they will, statements go out wrong, and the difference appears later as unexplained adjustments or a balance you can never collect. Audit every plan for your top in-network carriers.

Editing a plan without damaging history

When you change certain fields on a plan that other subscribers share, Open Dental asks how to handle it. The two choices are Change plan for all subscribers and Create new plan if needed. The first modifies the shared plan for everyone. The second splits off a new plan for the subscriber you are working on and leaves the others and their history alone.

The manual is explicit about one case: if an employer switches carriers, do not simply change the carrier on the existing plan for all subscribers, because that rewrites historical claims. Create a new plan with the new carrier, then move subscribers to it and drop the old plan from each patient. Dropping a plan does not change historical information.

Expensive mistake: editing benefits right after creating a new plan. Open Dental's manual warns that if you create a new plan and then edit benefit information before closing the window, the benefit change can apply to both the new plan and the original plan for all its subscribers. Close and reopen the plan before editing benefits.

Benefits, frequencies, and verification

Benefits live in the Benefit Information grid on the plan. Double-click the grid to edit (you need the Insurance Plan Edit permission). The default Simplified View covers most US dental plans; the row view exists for unusual category structures.

What to enter for every plan

Benefit year. Leave calendar year checked for January through December plans. For service-year plans, uncheck it and enter the starting month. Getting this wrong makes "remaining benefits" wrong for months.
Annual Max (individual and family). Open Dental needs this to calculate insurance remaining.
General Deductible (individual and family), plus category deductibles where the plan differs. A category deductible of zero means none; blank means the general deductible applies.
Category percentages for each insurance category. Categories themselves are defined in Setup > Family/Insurance > Insurance Categories.
Frequency limitations and age limits, set by code group, so estimates drop to zero when a patient has already used a benefit.
Waiting periods, which rely on the subscriber effective date being entered.
Ortho benefits: lifetime max, percentage, and age limit.

Benefits follow a hierarchy: a benefit on a specific procedure code overrides a category benefit, which overrides a general benefit. Use code-level entries sparingly, because they are easy to forget.

Insurance remaining and history from elsewhere

Open Dental calculates remaining benefits as the annual max minus insurance used and pending in the current benefit year. The Insurance Remaining grid shows in the lower right of the Treatment Plan module, and in the Account module when you hover over Ins Rem. If a new patient used part of their max at a previous office this year, record it with Adjustments to Insurance Benefits on the plan, or your estimates will assume a full maximum that does not exist.

Verification as a daily list, not a scramble

The Insurance Verification List (open Appointment Lists, then Ins Verify) shows upcoming appointments whose eligibility or benefits have not been verified within the windows you set. It separates patient eligibility (Pat), plan benefits (Ins), and both. Assign rows to specific team members and mark them verified; doing so updates the Eligibility Last Verified and Benefits Last Verified dates in the plan. The Past Due tab catches anything missed.

Verify benefits per plan (they are shared) but eligibility per patient. Once one person has verified an employer group's benefits this year, the next patient on that plan only needs eligibility confirmed. That split is how a single coordinator keeps up with a full schedule. Setup options for the list are in Setup > Appointments > Insurance Verification.

Fee schedules: the engine behind every estimate

Open the fee schedule list with Setup > Fee Schedules, or click Fee Scheds in the Procedure Codes list. Open Dental supports several fee schedule types:

Normal: your office fees (UCR) and each in-network contracted schedule.
CoPay: a set patient amount per procedure (capitation and flat co-pay plans).
Out of Network: amounts insurance allows even though you are not contracted.
FixedBenefit: the fixed dollar amount a PPO Fixed Benefit plan pays per code.
ManualBlueBook: known allowed fees, used when the Insurance Blue Book feature is enabled.

Which schedule Open Dental actually uses

This is the rule that trips people up. For PPO plan types, the fee billed on the procedure comes from the fee schedule assigned to the patient's primary provider (in the provider setup). The fee schedule on the insurance plan is used only to calculate the write-off. For Category Percentage and Medicaid or Flat Co-pay plans, Open Dental walks a hierarchy: the plan's fee schedule if one is assigned, then the patient's fee schedule, then the provider fee schedules in order. Provider or clinic fee overrides are applied after the schedule is chosen.

Question	PPO plan types	Category Percentage
Where does the billed fee come from?	Patient's primary provider's fee schedule	Plan fee schedule if assigned, otherwise patient, then provider schedules
What does the plan's fee schedule do?	Sets the allowed fee, which drives write-off and estimate	Can set the billed fee
Is a write-off calculated?	Yes: office fee minus allowed fee	No

A worked PPO estimate (hypothetical example)

This follows the calculation Open Dental documents for PPO plans. Hypothetical numbers: office fee $150, PPO allowed fee $127, patient has a $50 deductible remaining, and the category covers 80%.

Write-off = office fee minus PPO fee = $150 minus $127 = $23.
Covered amount = PPO fee minus deductible = $127 minus $50 = $77.
Insurance estimate = covered amount times percentage = $77 times 80% = $61.60.
Patient portion = office fee minus write-off minus insurance estimate = $150 minus $23 minus $61.60 = $65.40.

Check: $23 plus $61.60 plus $65.40 equals $150. Now imagine that plan had no fee schedule attached. There is no allowed fee, so there is no write-off, and the estimate is calculated on $150. The patient is quoted a portion that has nothing to do with your contract. Our PPO write-off calculator runs the same math if you want to sanity-check a quote.

Downgrades (alternate benefits)

Many plans pay a posterior composite at the amalgam rate. Open Dental models this with substitution codes. The universal setting is the Ins. Subst Code field in each procedure code (by default Open Dental links posterior composite codes D2391 to D2394 to amalgam codes). You can override it per plan: on the plan's Other Ins Info tab, click Subst Codes. The Don't Substitute Codes checkbox turns downgrades off for the whole plan. On a PPO, the write-off still uses the billed code's PPO fee, while coverage is calculated on the downgraded code's lower fee, so the patient pays the difference.

Keeping fee schedules maintained

When a PPO sends a new fee schedule, enter it into the existing schedule for that PPO (or copy and edit) from the Procedure Codes window. The Fee Tools button (lower right) offers Copy To, Export, Import, Clear, Increase by %, Update Proc Fees Only, and Update Estimates Only.
After changing fees, use Update Proc Fees Only to refresh fees on treatment-planned procedures. The manual notes this updates fees, not insurance estimates, and does not change saved treatment plans.
Run Update Estimates Only to recalculate estimates and write-offs. It can take a while, so run it after hours.
To find plans with a missing or wrong fee schedule, open Fee Schedules and click Go at the bottom to open Check Insurance Plan Fees. Filter for plans without a fee schedule, then bulk-assign the right one with Change Fee Schedule. Open Dental asks for a confirmation password (published in the manual) to prevent accidental bulk changes.

Expensive mistake: using Clear or Increase by % without a backup. Clear erases every fee in the selected schedule, provider, and clinic combination. A mistaken percentage increase on a contracted schedule silently shrinks your write-offs and inflates patient portions. Make a backup (see Module 8) and export the schedule before any bulk fee tool.

If you are deciding whether a PPO is worth keeping at all, the fee schedule you just loaded is the raw material. See Should You Drop a PPO? for how to run that analysis.

Secondary insurance and coordination of benefits

A secondary plan is simply the patient plan with Order 2. Add the primary first so ordering is automatic, and check the order any time a patient has more than two plans. Each plan has a COB Rule on the Other Ins Info tab; Open Dental's options are Basic, Standard, Carve Out, and Secondary Medicaid. Carve Out reduces the secondary payment by what primary paid; Secondary Medicaid also turns the leftover patient portion into a write-off for the secondary. Read the manual's Coordination of Benefits page before changing the default, and set the practice default in Family module preferences rather than plan by plan.

When you create a claim for a patient with two plans, Open Dental creates both claims at once: the primary with status Waiting to Send and the secondary with Hold until Pri received. When primary pays differently than estimated, the preference "Auto update secondary claim estimates when primary is received" updates the secondary estimate. Without it, click Recalculate Estimates on the secondary claim before sending.

Creating and sending claims

Creating the claim

Set procedures complete in the Chart module (covered in Module 4). Missing tooth numbers or surfaces cause rejections later.
In the Account module, highlight the procedures and click New Claim. If you click it with nothing selected, Open Dental creates claims for all unsent procedures. The dropdown offers Primary, Secondary, Medical, and Other.
Review the Edit Claim window: billing and treating provider, claim form, and estimates. Add attachments on the Attachments tab if needed (next section).
Set the status to Waiting to Send and save.

Claim statuses in Open Dental are: Unsent, Hold until Pri received, Waiting to Send, Probably Sent, Sent (verified), Received, and Hold for In Process (when a procedure is marked complete but still in process).

Turn on the preference "Require claims to have no missing data" if your team routinely creates claims with missing tooth numbers. It blocks primary claim creation until the procedure data is complete, which is far cheaper than a rejection two weeks later.

Sending claims

Electronic claims go through a clearinghouse. Set yours up in Setup > Family/Insurance > Clearinghouses. Open Dental lists DentalXChange (ClaimConnect) and Electronic Dental Services as recommended options and supports several others. You must pick default clearinghouses for Dental, Medical, and Eligibility. Sign up with the clearinghouse first, then enter its settings in Open Dental.

In the Manage module, click Send Claims. The grid lists claims with status Waiting to Send.
Click Validate Claims. Anything incomplete shows in the Missing Info column. Fix the underlying data (subscriber ID, payer ID, provider NPI, tooth number) and validate again.
Click Send E-Claims. Open Dental validates again before sending. Print paper claims with Print.
Click Get Reports (or let the Open Dental Service retrieve them automatically) to pull clearinghouse acknowledgments and rejections. Read them the same day.

The daily unbilled check

Procedures that never became claims are the most invisible leak in a practice. In the Send Claims window, click Procs Not Billed, or open Reports > Standard and choose Procedures Not Billed to Insurance under Monthly. The report lists completed procedures with a fee for patients with active insurance and lets you highlight procedures and click New Claims. The Claims Not Sent report, also under Monthly, catches claims created but never transmitted.

Preauthorizations and attachments

Preauthorizations

In the Treatment Plan module, highlight the procedures and click PreAuthorization in the toolbar. Pick the plan if the patient has more than one.
Send it electronically or print it. After it is sent, only users with the PreAuth Sent Edit permission can edit it.
When the carrier responds, double-click the preauthorization in the Treatment Plan module, click By Procedure, and type the carrier's estimate into the Estimate cell. Record the preauth number in remarks.

Those estimates become overrides on the treatment plan estimate. The manual notes you cannot enter estimated write-offs when receiving a preauth, so the displayed patient portion may be higher than the patient will actually owe on a PPO. Say so when you present the plan; case presentation goes better when the numbers are explained up front.

Attachments

The claim's Attachments tab has sub-tabs depending on your setup. The DXC tab (DentalXChange) and EDS tab (Electronic Dental Services) are integrated attachment services that send images with the claim. The NEA/Manual tab is for other third-party attachment services or paper: you record counts of radiographs and images, check boxes for EOB, narrative, or perio chart, choose By Mail or Electronically, and enter the Attachment ID Number the outside service gave you. Images added locally on that tab are for reference only; Open Dental does not send them.

What each carrier wants attached (radiographs, perio charts, narratives) varies by carrier and plan. When a claim comes back asking for records, add a line to that carrier's plan note so the next claim goes out complete the first time.

Following up on claims and working denials

The Outstanding Insurance Claims report

Open Reports > Standard, then Outstanding Insurance Claims under Monthly. Useful filters include days old (minimum and maximum), date range applied to date sent or date of service, preauth handling (include, exclude, or only), treating provider, clinic, carrier, assigned user, last custom tracking status, and last error. Select claims and click Assign User to divide follow-up among staff, and use Update Custom Tracking to change status on several claims at once.

Custom tracking

Every claim has a Status History tab. Click Add, choose a Custom Track Status (required), optionally pick an Error Code, add a note, and save. These notes do not print on claims. Build a small, consistent set of statuses before you start, for example: Called carrier, Resubmitted, Appeal sent, Awaiting records request, Patient contacted. If you pick "None," Open Dental warns that you will not be able to filter that claim by tracking status on the Outstanding report.

A denial workflow that closes the loop

Record the response. A denial is still a received claim. Receive it with $0 paid for each procedure (the mechanics are in Module 6), use the Pay Tracking dropdown to record the reason, and put the carrier's remark in Remarks.
Classify the cause. Most denials fall into a few buckets: eligibility (patient not covered on date of service), frequency or age limitation, missing information or attachment, non-covered service, or coordination of benefits.
Fix the source data. A frequency denial means your benefit frequencies are wrong or missing for that plan. An eligibility denial means verification failed. Fix the plan, not just the claim, or the next patient on that plan gets the same denial.
Correct or appeal. If the claim had wrong information, resubmit it as a corrected claim: on the Misc tab set Correction Type to Replacement and enter the carrier's Original Reference Number. The manual notes that most carriers do not support Void. If the claim was correct and the carrier is wrong, send an appeal with the supporting records the carrier's appeal process requires.
Track it. Add a custom tracking entry and assign it to a person with a date.
Decide on the balance. Whether a denied amount becomes the patient's responsibility or a write-off depends on your contract with the carrier and your financial policy. For in-network plans, check the contract before billing the patient.

Expensive mistake: "writing off" denials to make the report clean. Clicking a write-off on a denial ends the follow-up and hides the real reason. Over a year, a practice can lose a meaningful share of collections to denials no one appealed and plan setups no one fixed. Write off only when you have decided the money is not collectable from anyone, and use a specific adjustment or write-off note so you can report on it later.

Once a week, sort the Outstanding Insurance Claims report by carrier. If one carrier dominates the aged list, the problem is usually systemic (a wrong payer ID, a missing attachment rule, a plan set to the wrong type) rather than a string of bad luck.

For the bigger picture of how claims fit into collections and cash flow, read Insurance and the Revenue Cycle in the Operations track.

A weekly insurance hygiene routine

Frequency	Task	Where
Daily	Verify tomorrow's patients	Appointment Lists > Ins Verify
Daily	Validate and send claims, read clearinghouse reports	Manage > Send Claims
Daily	Bill anything missed	Send Claims > Procs Not Billed
Weekly	Work claims over 30 days old, update tracking	Outstanding Insurance Claims report
Monthly	Look for PPO plans with no fee schedule	Setup > Fee Schedules > Go
Monthly	Merge duplicate carriers, hide dead ones	Lists > Insurance Carriers
When contracts change	Load new fees, update proc fees and estimates	Procedure Codes > Fee Tools

Practice exercises

Do these in a test copy of your database or in the Open Dental trial, never on live data for the first run.

Module 5 exercises

Add a family where the spouse is the subscriber: enter the subscriber's plan first, then attach the patient and a child as dependents with the right relationships and order.
Create a PPO Percentage plan, attach a contracted fee schedule, and confirm that a treatment-planned crown shows a write-off. Then remove the fee schedule and watch the estimate change.
Enter a full benefit setup for a service-year plan: annual max, deductibles, category percentages, and a bitewing frequency limitation.
Run the PPO estimate from this module by hand on one real procedure and confirm Open Dental's numbers match.
Open Check Insurance Plan Fees and list every plan without a fee schedule. Decide which are genuinely out of network.
Run Procedures Not Billed to Insurance for the last 90 days and explain every line.
Pull the Outstanding Insurance Claims report for claims over 30 days old, assign them to a user, and add a custom tracking status to three of them.
Walk through a corrected claim: set Correction Type to Replacement and find where the Original Reference Number goes.

What's next

You now have clean plans, accurate estimates, and claims that go out and get followed. Module 6: Billing, Payments, and Accounts Receivable picks up when the money arrives: receiving and finalizing insurance payments, ERAs, patient payments, adjustments, statements, payment plans, and aging. If you skipped earlier modules, Module 1 covers the permissions that control who can edit plans and fees, which matters more after reading this one. The glossary defines terms like UCR, COB, and write-off if any of them were new.

ChairsideSource is not affiliated with or endorsed by Open Dental Software, Inc. This is independent educational content. Menus and features change between versions: verify against the official Open Dental manual and contact Open Dental support before changing settings that affect live patient data. This guide is educational content and does not constitute legal, financial, tax, or clinical advice. Laws and regulations vary by state and change over time. Consult your own dental-specific attorney, CPA, and state dental board before acting.