EZ 2000 Manual - Edit Claim

Claim

An insurance claim is created in the Account module after an appointment has been Set Complete. 

There are two ways to create a claim.
1.  In the toolbar, click New Claim. All procedures that have not been billed to insurance will have a claim created for them. If a secondary carrier needs to be billed, a secondary claim will be created with a status of 'hold'. 
2.  If you need more options over the claim, highlight specific procedures, then click New Claim, or click the drop down to create a primary, secondary, supplemental, or other Claim Type manually. This can be useful if the patient no longer has current coverage under an insurance plan, but you still need to send a claim.

It is recommended to leave the claim status as “Waiting to Send” and click OK. Then, the claim will show in the Claim Send window where it can be printed or sent electronically as a batch at the end of the day.  You can also preview, print or electronically send the claim directly by clicking one of the buttons at the bottom.

Claim Information
Below is information about claim fields.

Claim Status:  Every claim has a status.
- Unsent: Claim has been created, but not sent.
- Hold: For secondary claims that should not be sent until the primary claim is received.
- Waiting: Claim is ready to be printed or sent electronically.  It will display in the Send 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 the status on the Send Claims window to Sent.
- Sent: Claim has been sent and verified. It will no longer show in the Send Claims window. 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 back 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 claims are automatically created at the same time. The primary claim will have a status of Waiting to Send, and the secondary claim will have a status of Hold. The secondary claim stays in the patient's account with Hold status until the primary claim is received. Once the primary claim is received you can send the secondary claim, but be sure to verify the estimates on the secondary claim first.

Claim Type:  Set 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.

Dates:
- Date of Service: Should be the same date as the earliest procedures which are attached to the claim.
- Date Sent: Automatically filled in when creating the claim, but you can change it later.
- Date Received: Automatically filled in when Entering a Payment.
- Date Resent: Only filled in when a resending a claim.

To resend a claim, click Resend.

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.

Med/Dent: The insurance type that is set when you create the claim.

Claim Form: Select the Claim Form to use. This is important when billing medical claims.

Billing Dentist:  Set when the claim is created, but it can be changed.  By default, it is set to the Default Insurance Billing Dentist selected on the Edit Practice Info window. For Clinics, if the provider set as the Treating Dentist is assigned to a clinic, the Billing Dentist by default will be set to the Default Insurance Billing Dentist for that clinic, as selected on the Edit Clinic window.  Be sure that you assign the correct  provider for each procedure. 

Treating Dentist:   Set when the claim is created, but it can be changed.  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 the Treating Dentist will get set to the patient's primary provider.  Some claim formats require a treating dentist, and that is the reason for this field. You can still assign a different dentist for each procedure.

Predeterm Benefits/Preauthorizations:  If you have previously sent in a Preauthorization, enter the number you receive back 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 it can not be changed. If you attach the claim to the wrong insurance plan, delete the claim, then recreate it.

Relationship: Select this patient's relationship to the plan's subscriber. This is usually selected automatically, but can be changed. If changed, also change it in the Insurance Plan.

Other Coverage: Filled in automatically when you create the claim. For instance, if the patient has primary and secondary coverage, then this section would show the secondary coverage. You can change it at anytime (click Change), or remove information (click None).

Enter Payment/Split Claim
See Enter Insurance Payments.

Procedures
See Claim Procedures for information on how the procedures are attached and how to edit them.

Recalculate Estimates:  Use this button to recalculate benefit estimates.  This is useful if you treatment plan procedures with wrong percentages, and create a claim. After fixing the percentages, instead of deleting the claim, click Recalculate Estimates.  This is also useful for writeoffs if a fee schedule was originally incorrect.

Reasons Underpaid:  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.

Medical claims: The Ins Est column shows the 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.

Insurance Checks
See Enter Insurance Payments.

There are two separate steps for entering payments: .
1. First, you enter the payments for each patient separately using one of the three buttons at the upper right.
2. Then, you create the check that combines payments from multiple patients.

General Tab
The General tab has many fields that are used rarely and are for special insurance situations.

Misc Tab
The Misc tab has fields that are used rarely.

Medical-UB04
The Medical-UB04 tab only contains information that is printed on UB04 claim forms, which are usually used for institutional claims.

Troubleshooting
If you create a claim that has incorrect procedure codes, see Fixing Incorrect Procedures on an Insurance Claim.