Edit Claim Window
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.
Note: Change Healthcare users must update to version 16.2.62 and install .NET 4.5 on or before November 1, 2016 to retain electronic eligibility functionality.
Claim Status: Every claim has a status.
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.
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.
Billing Provider: The default billing provider follows the logic below:
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.
Procedures: 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.
Note: An orange exclamation mark will appear next to the button when recalculation of claim estimates is suggested.
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.
Questions and Answers
Q: In what order are deductibles and annual max applied?
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?
Open Dental Software 1-503-363-5432