Ortho Auto Claims

Use the Auto Ortho 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.

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:

  1. Set general ortho preferences.
  2. 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.
  3. 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 ortho claim date to update based on the plan's frequency.
  4. When the current day equals or is after the next claim date, the patient will list as a option when running the Auto Ortho Tool.
  5. Generate the ortho claims using the Auto Ortho Tool. The next ortho claim date will auto-populate with the next due date based on the plan's frequency.

Setup

The following items must be set up to use the Auto Ortho Tool.

In Ortho Setup:

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.


Schedule the Patient's Initial Treatment Procedure

As usual, schedule the patient's first initial treatment appointment with the corresponding orthodontic placement procedure.

  1. Schedule the appointment and attach the procedure.
  2. At the time of treatment, set the appointment/procedure complete. Doing so will update the next ortho claim date for the patient based on insurance plan ortho frequency setting.
  3. Check the Ortho Case tab to verify that dates and fees are accurate.
  4. Create the initial orthodontic claim and send as normal.

Generate Periodic Ortho Claims using the Auto Ortho Tool

Each month, check the auto ortho tool to see which periodic claims are due to be sent. The next claim date will always be the first of the month.

  1. In the Main Menu, click Tools, Auto Ortho Tool.

    Claims that meet the auto ortho claim criteria below will list:

    • Patient insurance plan is set to create automatic ortho claims.
    • The initial ortho treatment procedure has been completed.
    • The next claim date is today or prior.

    Column definitions:

    • 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 claim.
    • Next Claim: The date the next claim is due.
  2. 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.
  3. Click Generate Claims. A confirmation message will show.
  4. Click Yes to generate the claims.
  5. Another message will indicate when the process is complete, the number of claims generated, and the number of procedures added. Click OK.
  6. Click Close to close the Auto Ortho Claims window.

The claim will show in the Account module 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 Auto Claim Tool.


The Next Claim Date is typically auto-populated based on the last claim (the initial ortho claim or the last auto-generated 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:

How do I change the fee billed on the next claim?

The fee defaults to the fee set on the Edit Insurance Plan - Ortho tab. To override it for the next claim only, uncheck Use Default Fee, then enter the new fee.

Claim Payments

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.