Manage Claims

Claims outline the procedures performed on patients and the amounts charged. In order to collect insurance amounts for procedures, you must batch and submit all claims to the correct insurance companies.

Note: Batching groups a claim with other claims and indicates that it is ready to be submitted to insurance. This makes claim management easier.

Tip: axiUm may be configured to auto-batch all treatments/claims to the Print Held window or the EDI Claims window once a treatment has been approved. This is set from the Maintenance > Office > Practices > Practice Options > Auto batch claim upon Patient Approvals checkbox.

There are two reasons to batch and submit a treatment to insurance:

  • Receive pre-authorization: Some insurance companies require you to submit a pre-authorization for work before the treatment can be started. In this situation, the insurance company wants to review and approve the treatments before agreeing to provide coverage for them. Once received, you can begin treatment.

    • Note: Treatments that require pre-authorization are determined during setup.

    Important: In some cases, coverage may be partially or fully denied. The patient must be informed of the decision before treatment can begin.

  • Receive payment for work: This occurs after work has been done on a patient and the treatment’s status has changed to in process and/or completed, or an in progress visit has been added.

    • Important: In some cases, coverage is partially or fully denied, and the payment received reflects this decision.

    Note: The timing of when treatment should be submitted depends on your institution’s workflow and the insurance company receiving the claim.

    Example: A treatment has multiple step codes and requires several visits. A claim is submitted to the insurance company after each visit occurs until the treatment is complete.

Claims can be submitted to an insurance company in one of two ways:

  • Electronic Claims: Electronic claims can be batched and made ready for EDI submission from the Transactions module. They are then submitted electronically via the EDI Claims module.

    • Important: All electronic claims must later be submitted via the EDI Claims module or Maintenance > System > Processes > EDI Claims window.

  • Paper Claims: Paper claims are claims that have been dropped to paper. This means they are printed and mailed to the insurance company. Depending on the workflow used by your institution, they can be printed immediately or held to be printed at a later date.

    • Important: If holding to print at a later date, paper claims must be printed via the Maintenance > System > Processes > Print Held Claims window.

Some insurance companies need to review certain treatments before providing coverage for them.

Important: You can only submit planned treatments for pre-authorization.

  1. Select a patient and open the Transactions module.
  2. Click the Treatment tab > Planned sub-tab and review the listed treatments.
  3. Select a listed treatment and click the Submit… button to display the applicable insurance claim window.
  4. Complete the fields as necessary and click OK.

After submitting a planned treatment for review, you can enter the pre-authorization response you received from the insurance company.

  1. Select a patient and open the Transactions module.
  2. Click the Treatment tab > Planned sub-tab and review the listed treatments.
  3. Select a listed treatment, right-click and select PreAuthorization# to display the Tx PreAuthorization window.

  4. Complete the fields as necessary and click Save.
    5. Field Description
    Pre-Authorization Received?

    Select the checkbox to indicate a pre-authorization response has been received.

    PreAuth #

    Enter the pre-authorization number received from this insurance company.

    Note: The field holds a maximum of 20 and 14 characters for dental practices in the US and Canada, respectively.

    Effective

    Select the effective date from the calendar drop-down.
    Expiry Select the expiry date from the calendar drop-down.
    Response

    Select Accepted or Denied from the drop-down.
    Authorization Exception

    Note: This field is only enabled if the Response field is set to Denied.

    If necessary, you can override the denial with an authorization exception.

    Select an entry from the drop-down:

    • Immediate/Urgent Care
    • Retroactive Services
    • Emergency Care
    • Temporary Client
    • Request for 2nd Opinion
    • Override Pending
    • Special Handling

Batching groups a claim with other claims and indicates that it is ready to be submitted to insurance. Because a claim can only hold treatments for a single patient, submitting/printing claims individually would be cumbersome and time consuming; marking claims as batched allows them to be submitted/printed in larger groups which are easier to manage.

Treatments display in green text if they are not yet batched and have not been submitted to insurance.

  1. Select a patient and open the Transactions module.

  2. Click the Treatment tab > Treatments or Planned sub-tab and review the listed treatments.

  3. Select a listed record that is ready for submission and click the Submit… button to batch for submission.
  4. If prompted with an insurance claim window, complete/modify the fields as necessary and click OK.

If treatments have already been submitted to insurance and you must make changes to the treatment details, you must rebill the treatment/claim.

Example: If insurance information that affects the claim was entered incorrectly into axiUm, you must make the necessary changes in axiUm, then rebill the claim/treatment to apply those insurance changes.

Important: Because any changes made to insurance, procedures, or fee guides do not automatically affect submitted claims, you must rebill any claims impacted by the changes.

Depending which information was changed, you can choose to rebill the entire claim or just a treatment within that claim. If rebilling an entire claim, axiUm rebills all treatments on the same claim number. If rebilling a treatment, axiUm rebills only the selected treatment within that claim.

To rebill treatments/claims:

  1. Select a patient and open the Transactions module.
  2. Click the Treatment tab > Treatments sub-tab and review the listed treatments.
  3. If necessary, make all edits that will be reflected on the treatment/claim or the patient record.

    4. Note: Depending on the changes that are necessary, this may require leaving the Transactions module or accessing another module from within the Transactions module.

  4. Complete one of the following:
    • To rebill one treatment on the claim, right-click the treatment and select Rebill Treatment.
    • To rebill all treatments on the claim, right-click any treatment in the claim and select Rebill Claim.

    The Rebill Treatments window displays and the treatment(s) display in the Original Claim area.

  5. Complete the following for each treatment listed:

    1. Review and modify the fields as necessary.

      2. Field Description
      Practice

      Select the practice where the procedures on this claim were performed from the drop-down.

      Billing ID

      Select the billing doctor or fee schedule to be used for the rebilled claim entry.
      Dental / Medical / Both

      Select the correct radio button to indicate if this is a dental or medical treatment, or both.

      Note: If Medical or Both is selected, the fields in the Modify Tx section are enabled.
      Review Amts

      If necessary, you can review the totals and fees that will be submitted to insurance.

      Select the checkbox to display the Treatment Split window when you click the Add button.

      Facility

      Select the facility at which the treatments on this claim were performed.

      Note: This is required for medical claims, but optional for dental claims.
      Rebill

      Select a radio button to determine the appropriate patient insurance information:

      • Current Policies: This rebills the treatment using the policy information currently displayed in the Patients module > Patient Card window.
      • Original Policies: This rebills the treatment using the policy information used when the treatment was first submitted.
      • Policies Effective on Treatment Date: This rebills the treatment using the policy information in the Patients module > Patient Card window that was effective on the date of treatment.
      Dental Cd

      This displays the dental procedure code associated to this claim.

      If enabled and required, you can click the ellipsis to select from the Procedure Codes List window.

      Note: The Category drop-down only displays ADA entries.

      Medical Cd

      This displays the medical procedure code associated to this claim.

      If enabled and required, you can click the ellipsis to select from the Procedure Codes List window.

      Note: The Category drop-down only displays CPT entries.
      Site If enabled, enter the tooth site associated to this procedure.
      Surface If enabled, enter the tooth surface associated to this procedure.

    2. Click the Add button to move the treatment(s) to the New Claim area and display the amount charged.

    3. If the Treatment Split window displays, review and modify the Total and Coverage fields as necessary, then click OK.

  6. Click the Close button to exit the Rebill Treatments window.

    7. The original record is now struck out and a new record displays in the list.