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Auto Ortho Claim Generation

Use the Auto Ortho Tool to generate periodic orthodontic claims. This is useful when a carrier wants a claim submitted for the initial procedure, plus periodic claims based on a set frequency instead of a per visit. Once the initial orthodontic treatment procedure is set complete, the periodic claims are subsequently flagged for auto-generation based on the carrier's desired frequency, procedure, and fee. They will continue to flag for auto-generation until the total treatment time (Total Tx Time) is reached.

How it works:

  1. Set general ortho preferences.
  2. For each insurance plan, set the Ortho preferences. Ortho claim type must equal Initial Plus Periodic to be eligible for auto ortho claim generation.
  3. When the patient comes in for their first orthodontic treatment, set the initial orthodontic procedure complete and create the initial claim. This will trigger the 'next ortho claim' date to update based on the plan's frequency (see Ortho Case).
  4. When the current day equals or is after the 'next claim date', the patient will list as a option when running the Auto Ortho Tool.
  5. Generate the ortho claims using the Auto Ortho Tool. The 'next ortho claim' date will auto-populate with the next due date based on the plan's frequency.

The following items must be set up to use the Auto Ortho Tool.

General Ortho Setup (see Ortho Setup)

  • Check 'Show ortho case in account module' so the Ortho Case tab shows in the Account module and an Ortho tab shows on the Edit Insurance Plan window.
  • Set the default procedure code that will be used on orthodontic claims that are created automatically (Default Ortho Auto Proc).
  • Check 'Mark claims as Ortho if they have ortho procedures' so that 'Is Ortho' is always marked on automatically generated ortho claims.
  • Check 'Use the first ortho procedure date as Date of Placement' so that the 'Date of Placement' is always filled on automatically generated ortho claims.
  • Set which procedures will be considered initial orthodontic procedures (Ortho Placement Procedures).
  • Set how users can enter claim payments for claims generated using the Auto Ortho Tool (only enter on initial procedure's claim, or allow to enter on auto-generated claims).
  • Set other defaults as needed.

Insurance Plan Setup
For the insurance plan, specify the carrier's claim preferences on the Ortho tab (Edit Insurance Plan window). Any changes made here will affect all patients with the plan. To change next claim date or fee for a specific patient, see Determining the 'Next' Ortho Claim below.

  • Ortho Claim Type: Select ' Initial Plus Periodic'. Only plans with this option selected can generate claims using the Auto Ortho Tool.
  • Ortho Auto Proc: Select the procedure code to use on auto-generated orthodontic claims for this plan. Set the default in Ortho Setup. Click [...] to select a different procedure.
    Note: Only the first 5 digits of procedure codes are sent to insurance. In the example above, only D8670 is sent to insurance. The '.auto' portion of the procedure code is not sent to insurance, but is useful to identify and track codes on auto-generated claims.
  • Ortho Auto Fee: Enter the procedure fee to bill on the claim. 0 is a valid amount.
  • Auto Proc Period: Select how often the carrier requests a periodic claim (Monthly, Quarterly, Semi Annual, Annual).
  • Wait 30 days before creating the first automatic claim: If the insurance carrier requires that you wait a minimum amount of days after the initial completed procedure before sending the first periodic claim, check this box.

Schedule the Patient's Initial Treatment Procedure
As usual, schedule the patient's first initial treatment appointment with the corresponding orthodontic placement procedure.

  1. Schedule the appointment and attach the procedure.
  2. At the time of treatment, set the appointment/procedure complete. Doing so will update the 'next ortho claim' date for the patient based on insurance plan ortho frequency settting.
  3. Check the Ortho Case tab to verify that dates and fees are accurate.
  4. Create the initial orthodontic claim and send as normal.

Generate Periodic Ortho Claims using the Auto Ortho Tool
Each month, check the auto ortho tool to see which periodic claims are due to be sent. The 'next claim date' will always be the first of the month..

  1. In the main menu, click Tools, Auto Ortho Tool.

Claims that meet the auto ortho claim criteria below will list:

  • Patient insurance plan is set to create automatic ortho claims,
  • The initial ortho treatment procedure has been completed, and
  • The 'next claim date' is today or prior.

Column definitions:

  • TxMonths: Total months in treatment.
  • Banding: The date of the initial orthodontic procedure.
  • MonthsRem: The number of remaining treatment months.
  • #Sent: The amount of claims already sent.
  • Last Sent: The date of the last sent claim.
  • Next Claim: The date the next claim is due.
  1. Select the claims to automatically generate.
    • If using Clinics, optionally filter claims by clinic using the Clinic dropdown in the upper right.
    • Click Select All to select all claims.
  2. Cick Generate Claims. A confirmation message will show.
  3. Click Yes to generate the claims.
  4. Another message will indicate when the process is complete, the number of claims generated, and the number of procedures added. Click OK.
  5. Click Close to close the Auto Ortho Claims window.

The claim will show in the Account module with a 'waiting to send' status. The Auto Proc Code in the claim (e.g. D8670.auto) will also show in the patient's account. To send, see Sending Claims.

Determining the 'Next' Ortho Claim
There are two places to view when a patient's 'next' ortho claim is flagged for generation with the Auto Claim Tool.

  • Ortho Case, Next Claim.
  • The patient's insurance plan information: In the Ortho Case tab, double click the insurance plan area, or open the patient's insurance plan, then click the Ortho button in the Patient Information area.

How do I change the 'Next Claim Date'?
The next claim date is typically auto-populated based on the last claim (the initial ortho claim or the last auto-generated claim). To change the next date, simply change the date on the Ortho Patient Setup window. This can be useful if you need to skip a periodic claim or stop claims altogether.

A few hints:

  • The date will always be the first of any given month, so even if you enter 3/15/2017 it will change to 3/1/2017 upon clicking OK.
  • To stop auto generated claims, leave the next claim date blank. There will be no 'next claim' when this field is blank.
  • Once you manually set a date, it not auto-update until the next auto-generation of a claim.

How do I change the fee billed on the next claim?
The fee defaults to the fee set on the Edit Insurance Plan - Ortho tab. To override it for the next claim only, uncheck 'Use Default Fee', then enter the new fee.

Claim Payments
When generating auto-ortho claims, consider where claim payments should be entered: on the initial procedure's claim or on the auto-generated claim. To only allow staff to enter claim payments on the initial procedure's claim, check 'Block payments on ortho auto claims' in Ortho Setup. Then enter any installment payments as Supplemental Payments on the original claim and 'receive' auto-generated claims as zero payment claims.


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