Use the Ortho Auto Claims Tool to generate periodic orthodontic claims. This is useful when a carrier wants a claim submitted for the initial procedure, plus periodic claims based on a set frequency instead of per visit.
Note: The Auto Ortho tool cannot be used in conjunction with Ortho Case
Once the initial orthodontic treatment procedure is set complete, the periodic claims are subsequently flagged for auto-generation based on the carrier's desired frequency, procedure, and fee. They will continue to flag for auto-generation until the total treatment time (Total Tx Time) is reached.
How it works:
- Set general ortho preferences.
- For each insurance plan, set the Ortho preferences (Insurance Plan, Ortho tab). Ortho claim type must equal Initial Plus Periodic to be eligible for auto ortho claim generation.
- When the patient comes in for their first orthodontic treatment, set the initial orthodontic procedure complete and create the initial claim. This will trigger the next claim date to populate based on the plan's frequency.
- When the current day equals or is after the next claim date, the patient will list as a option when running the Ortho Auto Claims Tool.
- Generate the ortho claims using the Ortho Auto Claims Tool. The next claim date will automatically update based on the plan's frequency.
The following items must be set up to use the Ortho Auto Claims Tool.
In Ortho Setup:
- Check Show Auto Ortho in account module so the Auto Ortho tab shows in the Account module and an Ortho tab shows on the Edit Insurance Plan window.
- Set the default procedure code that will be used on orthodontic claims that are created automatically (Default Ortho Auto Proc).
- Check Mark claims as Ortho if they have ortho procedures so that Is Ortho is always marked on automatically generated ortho claims.
- Check Use the first ortho procedure date as Date of Placement so that the Date of Placement is always filled on automatically generated ortho claims.
- Set which procedures will be considered initial orthodontic procedures (Ortho Placement Procedures).
- Set how users can enter claim payments for claims generated using the Ortho Auto Claims Tool (only enter on initial procedure's claim, or allow to enter on auto-generated claims).
- Set other defaults as needed.
On the Edit Insurance Plan window, Ortho tab, specify the carrier's claim preferences. Any changes made here will affect all patients using the plan.
- Ortho Claim Type: Select Initial Plus Periodic. Only plans with this option selected can generate claims using the Ortho Auto Claims Tool.
- Ortho Auto Proc: Select the procedure code to use on auto-generated orthodontic claims for this plan. Set the default in Ortho Setup. Click [...] to select a different procedure.
Note: Only the first 5 digits of procedure codes are sent to insurance. In the example above, only D8670 is sent to insurance. The .auto portion of the procedure code is not sent to insurance, but is useful to identify and track codes on auto-generated claims.
- Ortho Auto Fee: Enter the procedure fee to bill on the claim. 0 is a valid amount.
- Auto Proc Period: Select the frequency of which the carrier requests a periodic claim (Monthly, Quarterly, Semi Annual, Annual).
- Wait 30 days before creating the first automatic claim: If the insurance carrier requires that you wait a minimum amount of days after the initial completed procedure before sending the first periodic claim, check this box.
Schedule the Patient's Initial Treatment Procedure
As usual, schedule the patient's initial treatment appointment with the corresponding orthodontic placement procedure.
At the time of treatment, set the appointment/procedure complete. Doing so will populate the next claim date for the patient based on insurance plan ortho frequency setting. This will be the date for the first Ortho Auto claim
Check the Auto Ortho tab to verify that dates and fees are accurate.
Manually create and send a claim for the ortho placement procedure.
Generate Periodic Ortho Claims using the Ortho Auto Claims Tool
Each month, check the Ortho Auto Claims Tool to see which periodic claims are due to be sent. The next claim date will always be the first of the month.
In the Main Menu, click Tools, Ortho Auto Claims.
Claims that meet the ortho auto claim criteria below will list alphabetically by last name:
- Patient insurance plan is set to Initial Plus Periodic (create automatic ortho claims).
- The initial ortho treatment procedure has been completed.
- The next claim date is today or prior.
- TxMonths: Total months in treatment.
- Banding: The date of the initial orthodontic procedure.
- MonthsRem: The number of remaining treatment months.
- #Sent: The amount of claims already sent.
- Last Sent: The date of the last sent Ortho Auto claim.
- Next Claim: The date the next Ortho Auto claim is due.
Note: Click name of column to change sorting.
Numerical sorting will use the same logic as alphabetical sorting. Rather than 1, 5, 10, you will see 1, 10, 5.
Select the claims to automatically generate. When Clinics is turned on:
- Optionally filter claims by clinic using the Clinic dropdown.
- Click Select All to select all claims.
Click Generate Claims. A confirmation message will show.
Click Yes to generate the claims.
Another message will indicate when the process is complete and the number of claims generated. Click OK.
Click Close to close the Auto Ortho Claims window.
Refresh the Account Module. The claim will show with a waiting to send status. The Auto Proc Code in the claim (e.g. D8670.auto) will also show in the patient's account. To send, see Send Claims.
Determining the Next Ortho Claim
There are two places to view when a patient's next ortho claim is flagged for generation with the Ortho Auto Claims Tool.
- Account Module: Auto Ortho tab, Next Claim. Double-click to open the Ortho Patient Setup window.
- Family Module: Double-click the insurance plan, then click the Ortho button in the Patient Information area
The Next Claim Date is automatically updated each time the Ortho Auto Tool creates a claim. To change the next date, simply change the date on the Ortho Patient Setup window. This can be useful if you need to skip a periodic claim or stop claims altogether.
A few hints:
- The date will always be the first of any given month, so even if you enter 3/15/2017 it will change to 3/1/2017 upon clicking OK.
- To stop auto generated claims, leave the next claim date blank. There will be no next claim when this field is blank.
- Once you manually set a date, it will not auto-update until the next auto-generation of a claim.
How do I change the fee billed on the next claim?
The fee billed to insurance on Ortho Auto claims defaults to the Ortho Auto Fee set in the insurance plan, Ortho tab unless it has been overridden for this patient in the Ortho Patient Setup window. To change the fee for only one patient on only one claim the simplest option is to edit the fee in the Ortho Patient Setup window prior to allowing the Ortho Auto Tool to create the claim.
Providers on Claims
The treating provider on the claim depends on the billing provider for the practice.
- If the treating provider (the provider on the procedure) matches the billing provider, then the treating provider on the claim is the same.
- If the treating provider (the provider on the procedure) is different than the billing provider, then patient's default primary provider will be the treating provider on the claim.
When generating auto-ortho claims, consider where claim payments should be entered: on the initial procedure's claim or on the auto-generated claim.
To only allow staff to enter claim payments on the initial procedure's claim, check Consolidate Ortho Insurance Payments in Ortho Setup. Then enter any installment payments as Supplemental Insurance Payments on the original claim and receive auto-generated claims as zero payment claims.