Understanding Claims

The insurance functions enable you to enter, edit, and print the following types of insurance claims:

Pre-authorization claimPre-authorization claim

Filed before treatment to confirm patient coverage with the insurance company; contains the patient’s diagnosis.
Actual claimActual claim

Filed at beginning of treatment, after services have been rendered (for example, when braces are placed).
One-time claimOne-time claim

Filed for a procedure/appliance with no recurring fees (for example, records or a splint).
Continuation of treatment claimContinuation of treatment claim

Filed on a monthly, quarterly, semi-annual, or annual basis when required by the insurance company, until treatment is completed or funds are exhausted.

In addition, you can use these options of the insurance functions feature:

Automated continuation of treatment claimsAutomated continuation of treatment claims

Enables you to generate continuation of treatment claims for multiple patients at one time.
Automatic claimsAutomatic claims

You can streamline insurance processing by configuring the software to automatically generate a claim when you post a procedure to a patient account. You can also set up the software to automatically generate claims when you enter a patient contract.
Claim reportsClaim reports

Claim reports produce a list of patients with claims that have been entered and specify whether or not the claims have been printed. The Missing Information Report for continuation of treatment claims details the information that is incorrect on Continuation of Treatment claims.
Bulk paymentsBulk payments

Insurance companies send one bulk reimbursement check with the payment EOB breakdown by responsible/patient party. The software enables you to post payments for all patients insured by a specific carrier at one time. There is no need to post a payment in each individual patient chart.
Electronic claimsElectronic claims

The OrthoTrac electronic claim service is an additional service that enables your office to electronically file insurance claims with those insurance companies that accept electronic claims. For an additional fee, you can choose to have the clearinghouse process paper claims by laser printing and mailing claims to insurance companies that do not process claims electronically, eliminating your need to process manual claims.

Click herehere for more information about the areas of the software that must be set up with insurance information in order to optimize the creation and processing of insurance claims.

Insurance Claim OptionsInsurance Claim Options

To ensure that the software generates and prints insurance claims according to the needs of your practice, and to set the type of claim you want the software to automatically generate, you must set up your preferences for insurance claims using the Insurance Claim Options function. You can also configure the software to automatically generate an Actual or Pre-Authorization claim when you enter a new contract. See Setting Up Insurance Claim Options for more information.
CarriersCarriers

Insurance carriers are set up prior to submitting a claim to the company. To do this, use the Carriers function. See Setting Up Carriers for more information.
EmployersEmployers

Employer information for each patient or responsible party must be linked to the carrier information. You can add the employer using the Carriers function, see Setting Up Carriers, or you can add both the carrier and the employer when adding a patient, see Adding Patient Information for more information.
ProceduresProcedures

You can configure the software to automatically generate a claim when certain procedures are posted to a patient account. You set up your procedure codes, including the ADA codes, using the Procedures function. See Adding Procedure Codes for more information.
OrthoTrac Electronic Claim ServiceOrthoTrac Electronic Claim Service

You can electronically send your claims to an insurance clearinghouse that verifies accuracy and then forwards the claims to those carriers that accept electronic claims. The clearinghouse prints and mails claims to carriers that do not accept electronic claims. See Using the eServices Setup Window for more information.

To automatically mark U for Unspecified Gender in field 14 of the ADA 2019 claim form for the Responsible Party, or in field 22 for the Patient, select this option in the respective Responsible Party Information or Patient Information windows. For more information, see Adding Responsible Party Information and Adding Patient Information.