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Managing Insurance Claims

Insurance claims can be sent, printed, and managed on the Insurance Claims window.

In the Manage module, click Send Claims.

This window is non-modal so you can open other windows while sending or validating e-claims.

Claims Waiting to Send
The top half of the window lists claims that have a status of 'Waiting to Send'.

  • Clearinghouse is determined by the insurance plan's setting for 'Don't usually send electronically' on the Edit Insurance Plan window. If checked, paper will list. If unchecked, the default clearinghouse will list.
  • Warnings: Indicates when a user attempts to send a deleted or already sent claim.
  • Missing Info: Indicates the claim's validation status. If 'validated when sending', the claim hasn't been validated for missing information yet. If missing information is listed, it must be completed before resending. Right click on the claim to Go To Account. If the column is blank, the claim has been successfully validated with no missing information found.

Filter options:

  • Clinic Filter: If using Clinics, list claims by clinic to more easily send each clinic's claims to a specific clearinghouse. The logged on user must have access to a clinic to view or send claims for that clinic. Click Next Unsent to jump to the next clinic with unsent claims.
  • Custom Tracking Filter: List claims by recorded claim tracking status. Custom tracking data is entered on the Edit Claim - Status tab.

Preview: View a claim before sending or printing.
Blank: Print a blank version of the default Claim Form.
Print: Print selected claims or, if no claims are selected, all 'paper' claims.
Labels: Print individual labels for selected insurance carriers.
Send E-Claims: Validate and send all e-claims to the clearinghouse listed in the Clearinghouse column, or click the dropdown to validate and send to a specific clearinghouse. See Send or Print Batch Insurance Claims.
Validate Claims: Validate selected e-claim(s) for missing information prior to sending.
Get Reports: Manually retrieve reports from a clearinghouse. See Reports below.
Refresh: Update the Claims Waiting to Send grid.
Procs Not Billed: Open the Procedures not Billed to Insurance report and optionally Create Batch Claims for unbilled procedures.
Close: Close the window.

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 History
The lower History grid lists all claims sent or printed from this window and received reports (e.g. ERAs, acknowledgement reports). Double click an item to view more information. Right click an item to Go To Account. The list of claims and reports can be filtered by date or type.

  • Date From / To: Only show claims and reports in a date range.
    • Manually enter the dates.
    • Click the down arrow to select dates from a calendar then click the up arrow to collapse the calendar.
    • Click the W buttons to jump back or forward one week. 
  • Type: Only show certain types of claims or reports. Single click an option, or to select multiple types, press Ctrl while clicking or Shift while clicking. If no options are selected, then all types will show.
    • ClaimSent 
    • ClaimPrinted 
    • Claim Ren: Renaissance claims.
    • StatusNotify_277: A health care claim 277 acknowledgment that notifies of claim status. See Acknowledgment Reports below.
    • TextReport: Any report that is not a 997, 999, 277, or ERA_835. See Text Reports below.
    • ERA_835: A electronic EOB, also known as electronic remittance advice or ERA. The AckCode indicates the ERA status. If blank, some or all claims on the ERA are not 'received'.  If 'Received', all claims have been received, but payment must be finalized. Double click an ERA to process it. Also see Electronic EOBs (ERA 835).
    • Ack Interchange
  • Undo: If there was a problem with sending, highlight the claims and click Undo. The claims will move back to the Claims Waiting to Send grid.
  • Print List: Print the current contents of the History grid.
  • Outstanding Claims: Open the Outstanding Insurance Claims report.

Claim History Grid

  • Patient Name: The patient that is attached to the claim.
  • Carrier Name: The insurance plan attached to the patient.
  • Clearinghouse: The clearinghouse that the claim was sent to, where applicable.
  • Type: Displays the type of claim or report. See Type, above.
  • AckCode: The status on a 277response. This column will show "A" or "R" (accepted/rejected).
  • Note: Double click the item to enter a note in this column.
  • User: The logged-on user that sent the claim, where applicable.

Note: In order for a report to list, it must already exist in the clearinghouse's default Report Path. You can set up automatic download (see Clearinghouse Setup), manually download (click Get Reports), or manually save the report file in the correct folder. Not all insurance carriers offer ERAs, reports, or the ability to automatically download. 

Claim Details
To view details about a sent claim, double click it. 

If there is ever any need to troubleshoot a sent claim, the full text of the batch is saved here. Most of the text, as well as the fields below, are meaningful only to technical support.

Attachments Sent: Indicates if attachments were sent.
Note: Add a note that will display on the Insurance Claims window.
Acknowledgment: If the transaction has been acknowledged by the clearinghouse, then that information, including the full Message Text and Date/Time, will show at the right.

Reports
In order for a report to list in the History grid, it must first be downloaded to the Clearinghouse Report Path.

  • To set up automatic download, see Clearinghouse Setup. Only certain clearinghouses allow automatic download.
  • To manually download, click Get Reports or manually save the report file to the correct report path.

Note: If you are using Change Healthcare, update to version 16.2.62 and install .NET 4.5 by November 1, 2016 to retain claim report functionality.

Acknowledgment Reports
There are 4 types of acknowledgment report formats: 997, 999, 277, and 835. They are listed in the order in which they are received from the clearinghouse.  Clearinghouses are not obligated to provide these acknowledgment reports and may choose to return some or all reports for some batches and not others. 

997 & 999: Open Dental has supported format 997 (functional acknowledgement) for years. Support for format 999 (implementation acknowledgement) was added in Version 12.3. The 997 and 999 are simpler formats that only provide information regarding the status of a batch based purely on formatting and data requirements. When a 997 or 999 is received by Open Dental, the AckCode column in the History grid for the corresponding claims are set to 'A' for accepted or 'R' for rejected. To view the acknowledgement message text, double click on the sent claim. 

277: Shows in the History grid with a Type of StatusNotify_277. This report provides more detailed status information about the 'sent' batch than a 997 or 999 format. Support for the 277 format was added in Version 12.3. See 277.

835: Also known as the electronic remittance advice or ERA. The 835 report shows in the History grid with a Type of ERA_835. See ERA 835,

Text Reports
Reports usually come back from the clearinghouse as files placed in the report path specified in the Edit Clearinghouse window. They are then automatically imported by Open Dental and stored in the database. The original text file is deleted. Older versions of Open Dental did not store the report in the database, but instead moved the file to an archive folder. Because of the new way that reports are handled, it is no longer important to always run e-claims from the same workstation. However, if you use Tesia, then TesiaLink should only be running on one computer at a time. Also, there is no need to manually archive reports.  Reports that have been imported will show as rows in the lower history grid. Double click on the row to view or print. Use the Note field to make comments about each report that you will find useful.

Some clearinghouses use a web-based followup system rather than sending back text reports.

 

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