Medical E-Claims

When sending Medical Insurance, review the following to ensure claims are accepted.

Insurance Plan: On the Insurance Plan, Plan Info Tab, check the Medical Insurance box. This is used for medical and institutional claims, and controls whether claims go out in dental format or in medical/institutional format. Also set the Claim Form to UB04 or 1500, in case you print paper claims.

Setup: In Preferences, there is a checkbox for Set medical claims to institutional when using medical insurance. This setting will affect all insurance plans set as 'medical' and determines whether claims are created as medical (837-P) or institutional (837-I). The user can change this option for individual claims (see below).

Claim: Create the medical claim in the Account Module. If the patient has dental insurance and medical insurance, create the medical claim by selecting the procedure(s) and clicking the New Claim dropdown in the toolbar, then Medical.

The Med/Dent and Claim Form settings can be changed on the Edit Claim window.

Clearinghouse: In Clearinghouses, set a default for dental and a separate default for medical/institutional. Dental clearinghouses cannot accept medical or institutional claims. If you will generate claim files from Open Dental and upload them manually to Medicaid, you still need to set up a clearinghouse to specify the Claim Export Path. The format for dental claims can be 4010 or 5010, and you can freely switch between them as needed. Medical and institutional claim format will be only 5010.

Send Claims: When Sending Claims, send batches of claims to one clearinghouse at once. [Technical note: To determine the format, information is required from both the claim.MedType and the clearinghouse.Eformat. Neither alone is sufficient.] Once messages are generated, they are archived in the etrans table in the database for later retrieval. These archived claims may be seen in the history list at the bottom of the Insurance Claims window. All 4 claim types (med5010, inst5010, dent5010, dent4010) will show as "claim sent" in the archival.