A Claim Procedure (ClaimProc) is used for the following purposes:
- To attach procedures to claims.
- To split insurance payments on claims.
- To record total insurance payments on claims. These payments are not attached to procedures.
- To store insurance estimates before a claim is created.
In a typical situation:
- While treatment planning, a Procedure is created.
- A ClaimProc is automatically added to the procedure to keep track of its estimated insurance portion. Change the estimate by changing the ClaimProc.
- When the Claim for the procedure is created, the ClaimProc links the procedure to the claim.
- When viewing the claim detail, all procedure estimates and payments are stored in the ClaimProc rather than with the procedure. This allows you to send an unlimited number of claims for each procedure and to have very fine control over all estimates and payments for each claim.
- When Receiving a Claim Payment, it can be itemized by procedure or entered as a total payment.
Edit a ClaimProc
On the Edit Claim window, double click on a procedure, or double click an estimate on the Procedure Info window, Financial tab.
Change the information as needed, then click OK to save. The logged on user must have the correct Permission to edit writeoffs and writeoff estimates.
Ins Plan: The Insurance Plan and subscriber. ClaimProcs are always associated with one insurance plan whether they are an estimate or attached to a claim.
Status: The status of the claim procedure.
- Estimate: Not yet attached to a Claim. Claim Info in lower right will not be visible. Estimates never affect the patient balance.
- Not Received: Attached to a claim with a Waiting or Sent status.
- Received: Attached to a claim with a Received status. Should also be attached to an Insurance Payment.
- PreAuthorization: Attached to a Preauthorization.
- Supplemental: Indicates a second payment on the same procedure. Much of the estimates will be 0. Almost identical to Received.
- If the insurance plan is a Capitation plan the statuses below apply:
- CapClaim: Since most capitation procedures are not sent to insurance there will always be duplicate ClaimProcs for a procedure (similar to Supplemental). The first ClaimProc tracks the co-pay and writeoff and is never attached to a claim (status = CapComplete). The second ClaimProc has status of CapClaim.
- CapEstimate: Not yet attached to a claim or for a procedure that is treatment planned (TP). When procedure is completed, status can be changed to CapComplete but never to anything else.
- CapComplete: Only set when procedure is set Complete. This stores the co-pay and writeoff amounts. The co-pay is only there for reference; the writeoff affects the balance. Never attached to a claim.
- (Adjustment: A hidden type set in the upper section of the Edit Insurance Plan window using a completely different interface. You don't need to worry about it.)
Payment Tracking: Document information about the payment of the procedure. Useful to track why payment was rejected. Options available are defined in Definitions, Claim Payment Tracking.
Provider: The Provider who performed the procedure. Click [...] to change.
Clinic: Only visible if Clinics is turned on in Show Features.
Pay Entry Date: The date the related insurance payment was entered. Used to track account aging.
Payment Date: Can be edited.
Procedure Date: The date the procedure was performed. Used to track annual benefits used.
Description: The Procedure Code description.
Claim: Indicates if this ClaimProc is an estimate or has been attached to claim. If part of a claim, the following information shows:
- Code Sent to Ins: The procedure code sent to insurance. Usually it is the same as the actual procedure code, but may be different if using alternate codes (e.g. for Medicaid), Medical codes or custom codes with suffixes that get removed before being sent.
- Fee Billed to Ins: The amount billed to insurance. Usually it is the same amount you billed the patient, but does not need to be. If 'Claims show UCR fee' is checked on the Edit Insurance Plan window, the amount shown is the Provider's UCR fee. So the claim may go out with a fee of $105, but the patient will only be billed $100.
- Remarks from EOB: EOB remarks that explain why insurance did not pay as expected on this procedure.
Do Not Bill to Insurance: Only used when the ClaimProc is an estimate. Indicates that this ClaimProc will remain an estimate and never be attached to a claim.
Estimate Information: Located at the top right. Changing information will not change the patient's balance.
- Fee: The actual fee billed to the patient as entered on the Procedure Info window.
- Fee Schedule: The fee schedule of the insurance plan listed first in the Family module. If this is a medical procedure code, this fee schedule may not accurately indicate where the fee is pulled from.
- Substitution Code: The Ins Subst Code entered for the Procedure Code. Used for situations like posterior composites, where the insurance company
downgrades it to the rate of an amalgam.
- PPO Fee Schedule: The fee schedule set for Patient Co-pay Amounts on the Edit Insurance Plan window.
- Allowed Fee Schedule: The fee schedule set for Carrier Allowed Amounts on the Edit Insurance Plan window.
- Allowed Amt: Frequently, insurance companies do not allow the full fee because
they claim it is above UCR for the area. In these cases, enter the allowed fee that should be used
for all calculations instead of the Fee. If this is a PPO plan, an allowed amount may already be entered. Click Edit Allowed Amt to change the amount in the fee schedule. When entering Insurance Payments, there is also a column for allowed amounts, and these flow into the out of network fee schedule if one is set for the insurance plan (Edit Insurance Plan window, Carrier Allowed Amount). Out of network fee schedules can be auto-generated using the Blue Book feature.
- Patient Copay: Based on the Insurance Plan's Co-Pay fee schedule. Two different uses:
1. For capitation, this automates calculation
2. For any other insurance, it gets subtracted from the amount that insurance will pay.
- Deductible: The amount (usually small, like $50) that the patient must pay each year
before insurance kicks in. Usually waived on preventive procedures. As of version 6.7, always subtracted before percentage is calculated. Deductibles.
- Percentage %: The percentage that insurance is expected to cover, based on a plan's Benefits.
Paid By Other Ins: Adds up all amounts paid by insurance plans that are lower in order. For example, it will never contain an amount if this is primary insurance.
- Base Estimate: For situations where the treatment plan needs to show without max or deductible taken into account. This field stores the value to show. Calculated as
((Fee or Allowed)-Copay) x (Percentage or Percent Override).
- Ins Estimate: Does not take deductibles and annual max into account. This value is the one shown in most places as the estimate. It depends on the order of treatment in the treatment plan. If the ClaimProc
is already attached to a claim, this will not affect the patient balance and you should
use Insurance Estimate under Claim Info instead.
- Write Off Estimate: Usually only used for PPO plans. This shows as a column in the treatment plan.
- Estimate Note: Contains automatically generated notes about annual max that will also show in the treatment plan.
Claim Info: Claim information is in the lower right. If the ClaimProc is still an estimate, the lower portion will not be visible. Once attached to a claim, the lower section can only be edited from within a Claim.
- Deductible: The actual deductible as reported by the insurance company.
- Insurance Estimate: The official amount estimated to be paid. Affects patient balance. Gets copied from Insurance Estimate when claim
is created. After that, it can only be changed manually.
- Insurance Paid: Once insurance pays, this is the amount actually paid
on this procedure. Cannot be edited once the procedure is attached to a check.
- Write Off: Amount not covered by insurance that office decides not to charge
the patient. This is how Capitation is handled as well as assignment of benefits where provider
has agreed not to charge above a set amount.
- Estimated Patient Portion: The estimated amount the patient is responsible for after insurance and writeoffs (Fee - Insurance Estimate - Write Off).
Attached to Insurance Payment Plan: This box is automatically checked if this ClaimProc's Insurance Payment is attached to a Insurance Payment Plan. You can also check this box manually, if , for instance, you enter a payment first, then decide to create a payment plan.
Questions and Answers
Q: What happens to the insurance estimate (Ins Estimate) when a claim procedure status is 'received', yet the insurance plan is dropped and replaced with a new plan?
A: The estimate for the original claim procedure is set to 0. Once the new plan is entered, opening a procedure (and clicking OK), or creating a claim will result in a new claim procedure and new insurance estimate for the new primary insurance plan.