Claim

Create, send and receive claims for indivdual patients from the Edit Claim window.

In the Account Module toolbar, click New Claim.

Alternatively:

Note:
  • Clicking New Claim, without selecting any procedures, automatically creates a claim for all procedures not sent to insurance. If there is dual coverage, a secondary claim is also automatically created with a status of Hold until Pri Received.
  • For more control, highlight specific procedures, then click New Claim, or click the drop down to create a Primary, Secondary, Medical, or Other claim type.

See our Webinar: Creating Claims

Once created, the claim will show in the patient's account under the procedures.

To send, print, edit, or delete a claim, the logged-on user must have the correct Security Permissions. This window is read-only if the logged-on user doesn't have access to the clinic on the claim or the clinic on the claim is hidden.

Note:
  • When a patient has unearned income and the preference, Prompt user to allocate unearned income after creating a claim, is checked, the user is prompted to Allocate Unearned Income when a claim is created.
  • Editing a claim with supplemental claim transfers created by the Income Transfer Manager will delete all the transfer entries on the claim. See Supplemental Insurance Payments.
  • Edits to the claim payment or write-off are logged in the audit trail.

Claim Status, Claim Type, and Dates

Claim Status: Every claim has a status.

When a claim is created using the New Claim button 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).

Note:

Claim Type: Set automatically when creating a claim. It is there for reference, but cannot be changed, because it affects so many other fields. See Claim Types.

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.

Resend: Resend a claim. Users will have two options:

Note: The Original Reference Num (Edit Claim - Misc Tab) is required before a claim with a Correction Type of Replacement can be sent.

Claim and Provider Information

Clinic: This will match the clinic assigned to procedures in the claim.

Med/Dent: There are three options; Dental, Medical, and 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 claim form (Claim Forms). 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 and 2018 Claim Forms. This does not affect what is sent electronically.

Billing Provider: The default billing provider follows the logic below.

Different providers can be assigned to each procedure. When providers are restricted to specific clinics (User Edit), 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 provider, then it will be the patient's primary provider. Some claim formats require a treating provider. Different providers can still be assigned to each procedure. When providers are restricted to specific clinics, only providers available for the claim's clinic are options.

Predeterm Benefits/Preauthorizations: If a Preauthorization has previously been sent, 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 Edit Claim - Misc Tab.

Insurance Plans

Insurance Plan: Set when creating the claim and cannot be changed. If the claim is attached to the wrong insurance plan, delete the claim and recreate it.

Relationship: The patient's relationship to the plan's subscriber, based on the value 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.

Enter Payment

Enter Payment:

Procedures and Estimates

Procedures: The procedures attached to this claim, along with billed fees and insurance estimate information. Double click a procedure to see details. See Receive Claim for a description of each column.

Recalculate Estimates: Recalculate benefit estimates. For example:

Note: An orange exclamation mark will appear next to the button when recalculation of claim estimates is suggested.


Medical claims: The Ins Est column 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. See Medical Insurance.

There are limits to the number of procedures that are sent with a claim.

Finalize Insurance Payments and Additional Payment Information

View ERA: Access ERAs associated with the claim. ERAs can only be accessed when claim identifiers and service dates match.

View EOB: View scanned EOBs for attached insurance payments. If there are more than one a selection list will appear.

Batch: Attach received claims to a batch insurance payment. See Finalize Insurance Payment.

This Claim Only: Finalize payment by attaching only the current received claim an insurance payment.

Reasons Underpaid: Enter details if a claim does not pay as much as expected, enter details about why. This information shows on the patient's statement so they know why they have to pay more for their procedures.

Tabs

General Tab: Enter information about prosthetics, orthodontic work, and claim referrals. See Edit Claim - General Tab.

Attachments Tab: Enter information about attached images and documents. If needed, attachment IDs should be added to the claim before sending claims electronically. See Edit Claim - Attachments Tab.

Misc Tab: Enter information about Denti-Cal and other miscellaneous fields. See Edit Claim - Misc Tab.

Medical Tab: Enter information printed on medical claim forms, including the UB-04, which is usually for institutional claims. See Edit Claim - Medical Tab.

Status History Tab: Record custom claim tracking data. See Edit Claim - Status History Tab.

Print, Send, or Save Claim

Delete: Delete a claim.

Label: Print a label for the claim.

Preview: Preview the claim as it would look on the printed claim form.

Print: Print the claim.

Note: Printing a claim automatically changes its status to sent.

Send: Send the claim electronically.

History: View electronic claim message. Displays as raw data (X12).

OK: Save the claim information.

Cancel: Close the window without saving.