Edit Claim Window
To open the Edit Claim window, click New Claim or a drop down option in the Account module, or double click an existing claim. Also see Claims.
To send, print, edit, or delete a claim, the logged on user must have the correct security Permissions. If using Clinics and the logged-on user doesn't have access to the clinic on the claim, the window is read-only.
Claim Status: Every claim has a status.
- Unsent: Claim has been created, but not sent.
- Hold until Pri received: For secondary claims that should not be sent until the primary claim is received.
- Waiting to Send: Claim is ready to be printed or sent electronically. It will display in the Insurance Claims window.
- Probably Sent: Claim has been printed or sent electronically, but the process has not yet been verified. As soon as you are sure the claim has been sent or printed, change its status.
- Sent - Verified: Claim has been sent or printed. It will show on the Outstanding Insurance Claims report so that you can track it and make sure it gets paid in a timely manner.
- Received: Claim has been received from insurance, either with a payment or denied for some reason. Usually the claim is marked received automatically when you click one of the Enter Payment buttons at the upper right.
When you create a claim for a patient with dual coverage, both a primary and Secondary Claim are automatically created. The primary claim will have a status of 'Waiting to Send'. The secondary claim will have a status of 'Hold until Pri received' and will stay in the patient's account. When the primary claim is received send the secondary claim (verify the estimates on the secondary claim before sending).
Claim Type: Set automatically when you create the claim. It is there for reference, but you are not allowed to change it because it affects so many other fields. See Claim Types.
Dates: Automatically filled in.
- Date of Service: Defaults to the date of the earliest procedures attached to the claim.
- Date Orig Sent: The date the claim was originally sent.
- Date Sent: Populates with the date the claim was created, and updates when the claim is sent. When a claim is resent, the label changes to Date Resent and the date is updated.
- Date Received: The date the claim was received and processed. See Insurance Claim Payments.
Resend: Resend a claim. This message will show.
If you choose the first option, the claim Correction Type (Misc tab) will be set to Original, the Date Resent will be set to today's date, then the claim will be sent electronically. If the second option is chosen, the Correction Type will be set to Replacement, then the claim will be sent electronically.
Clinic: Is using Clinics, this will match the clinic assigned to procedures in the claim.
Med/Dent: There are three options: Dental, Medical, Institutional. The default selection is based on the Claim Type. This setting is used for e-claims and determines whether the e-claim format is dental, medical, or institutional.
Claim Form: The default form is set in Claim Form Setup. To change, click the dropdown.
For information on how a printed 1500 claim form is populated, see HCFA 1500 Claim Form.
For information on how a printed ADA 2012 claim form is populated, see ADA 2012 Claim Form.
Billing Provider: The default billing provider follows the logic below:
- If the treating provider has a Claim Billing Prov Override set in Provider setup, that provider is used.
- Otherwise, for Clinics, if the procedure is assigned to a clinic, the Default Insurance Billing Dentist for that clinic is used (Edit Clinic window).
- Otherwise, the Default Insurance Billing Dentist for the practice is used (Edit Practice Info window).
You can also assign a different provider for each procedure. If using Clinics and providers are restricted to clinics in Security, only providers available for the claim's clinic are options.
Treating Provider: By default is the last provider in the list of selected procedures who is not flagged as a secondary provider. If there are only providers flagged as a secondary providers, then it will be the patient's primary provider. Some claim formats require a treating provider. You can still assign a different provider for each procedure. If using Clinics and providers are restricted to clinics in Security, only providers available for the claim's clinic are options.
Predeterm Benefits/Preauthorizations: If you have previously sent in a Preauthorization, enter the number received from insurance. In older versions there was a single PreAuth Number field. In newer versions, this is renamed Predeterm Benefits. This number shows on E-Claims and printed claims (PreAuthString). On the Misc tab there is also a Prior Authorization (rare) field (see below).
Insurance Plan: Set when you create the claim and cannot be changed. If you attach the claim to the wrong insurance plan, delete the claim, then recreate it.
Relationship: The patient's relationship to the plan's subscriber. The default value is set in the patient's Edit Insurance Plan window.
Other Coverage: If there are multiple insurance carriers, this auto-populates. For instance, if the claim is to the primary insurance, and the patient also has secondary coverage, the secondary coverage shows. Click Change to select a different plan. Click None to remove this information from the claim.
The procedures attached to this claim, along with billed fees and insurance estimate information. See Claim Procedures for information on how the procedures are attached and how to edit them.
- There are limits to the number of procedures that are sent with a claim.
- Dental and medical e-claims are limited to 50 procedures. If you attach more, you will be blocked from sending the claim.
- Institutional e-claims are limited to 999 procedures.
- On printed claims, only as many procedures as will print on a single page (the claim form) will be sent. The printed ADA-2012 claim is limited to 10 procedures.
- Recalculate Estimates: Recalculate benefit estimates. For example:
- If you treatment plan procedures with the wrong percentages and create a claim before fixing the percentages, recalculate instead of deleting the claim.
- If a fee schedule was originally incorrect, recalculate writeoffs.
- Add adjustment: Right click on a procedure to create an adjustment. The Account Module Preference, Insurance tab, 'Allow procedure adjustments from claim window' must be enabled.
Note: An orange exclamation mark will appear next to the button when recalculation of claim estimates is suggested.
Columns requiring additonal description:
- Fee: This is the fee charged to the patient's ledger and will show in the Account module. This column is informational and does not have a total.
- Ins Fee: This is the amount billed to insurance for the procedure.
- Ins Est: Insurance estimates for the insurance plan listed first in the Family module. These insurance estimates can be misleading if the patient has one dental insurance plan listed first and one medical insurance plan listed second. In this particular situation, the Ins Est column will always say 0, because it is showing the dental insurance estimates. To avoid this issue, ensure that the medical plan is listed first in the Family module.
General Tab: Enter information about prosthetics, orthodontic work, and claim referrals. See Claim Edit - General Tab.
Attachments Tab: Enter information about attached images and documents. See Claim Edit - Attachments.
Misc Tab: Enter information about Denti-Cal and other miscellaneous fields. See Claim Edit - Misc Tab.
Medical Tab: Enter information printed on medical claim forms, including the UB-04, which is usually for institutional claims. See Claim Edit - Medical Tab.
Status History Tab: Record custom claim tracking data. See Claim Edit - Status History Tab.
Note: Printing a claim automatically changes its status to 'sent'.
The Edit Claim window also is used to enter insurance payment information. See Enter Insurance Payments.
Questions and Answers
Q: How do I fix a claim that has incorrect procedure codes?
A: See Fixing Incorrect Procedures on an Insurance Claim.
Q: In what order are deductibles and annual max applied?
A: Deductibles and annual max are applied in the order that claims are created, not by procedure date.
Q: I have resent a claim and I want the insurance estimate to still apply to the patient's account.
A: By default, when you resend a claim that has already been received, the received amount, whether $0 or some other dollar amount, is applied to the account balance. If instead you want the insurance estimate to be reflected in the patient's estimated balance, simply change the status of the claim procedure(s) inside the claim to 'Not Received' instead of 'Received'. See Claim Procedure.
Q: When trying to create a claim I receive this message "Claim has more than 4 unique diagnosis codes. Create multiple claims instead." Why does this happen and what should I do when I have more than 4?
A: This happens when the procedures in the claims have more than 4 unique diagnosis codes among them. The claim format is limited to 4 unique diagnosis codes per dental claim.
A diagnosis code may be reused in procedures, but there can be only 4 unique codes. If there are more than 4 unique diagnosis codes, you have two options.
- Divide the procedures (and diagnosis codes) into more than one claim.
- Only include 4 diagnosis codes in the claim (drop the others).