Insurance Claim

Complete

This is the screen used to create, edit or view an insurance claim for a patient.

The fields are as follows:

  • Claim Number
 the number assigned to the claim by the insurer.
For claims submitted online, this will be set on submission.
  • Date
 the date the when the claim was created
  • Completed Date
 the date the when the claim was settled, declined or cancelled
  • Insurer
 the insurer for the policy
  • Policy Number
 the policy number
  • Gap Claim

indicates if the claim is a gap claim.
Only displayed for online claims, and when the insurer supports gap claims.
  • Author
 the user that created the claim
  • Claim Handler
 the user responsible for handling the claim. If necessary, the insurer may contact the Claim Handler with queries about the claim.
  • Location
 the practice location where the claim is being made
  • Clinician
 the clinician responsible for the claim
  • Amount
 the total amount of the claim
  • Tax
 the total tax of the claim
  • Claim Status
 the current status of the claim
  • Gap Claim Status
 the current gap status of the claim. Only displayed when Gap Claim is ticked, and when viewing the claim.
  • Benefit Amount
 the benefit amount agreed by the insurer. Only displayed when Gap Claim is ticked, and when viewing the claim.
  • Benefit Notes
 notes on the Benefit Amount, set by the insurer. Only displayed when Gap Claim is ticked, and when viewing the claim.
  • Notes
 optional notes
   

Conditions

The Conditions tab lists the conditions being claimed.

The fields are as follows:

  • Claim Number
 the number assigned to the claim by the insurer.
For claims submitted online, this will be set on submission.
  • Treatment Start
 the date that treatment for the condition commenced
  • Treatment End
 the date that treatment for the condition ceased.
If the condition is ongoing, this represents the last date when treatment for the condition was given to the patient, within the practice.
  • Amount
 the total amount of charges being claimed for this condition
  • Tax
 the total tax on the charges being claimed
  • Status
 the status of the condition
  • Notes
 a synopsis of the the condition being claimed
  • Charges
 the charges being claimed for the condition

Conditions can be added using:

  • Add
 Adds a Condition that requires the user to fill in all of the fields manually
  • Add Visit
 Adds a Condition where the fields and the charges are filled in automatically from the selected Visit
  • Add Problem
 Adds a Condition where the fields and the charges are filled in automatically from the selected Problem

Attachments

The Attachments tab lists the attachments that will be submitted as part of the claim. These are a copy of the original documents, taken when the claim is submitted.
To see what documents will be attached, click the Generate Attachments button.

The following attachments will be automatically added:

  • Patient History - the full patient history up to the time of the claim
  • Customer Invoice - an invoice will be added for each invoice referenced by the claim

History

The History tab displays the patient history, and is provided to help construct the claim.
It does not represent the history that will be attached to the claim when it is submitted.

Gap Claims

A gap claim is one where an insurance claim is submitted to the insurer, and the insurer calculates a benefit amount. The customer pays the gap, which is the difference between the total claim and the benefit amount, minus any payments the customer has already made.

Gap claims are only available for online insurers.

When Gap Claim is selected and the claim is submitted, the Gap Claim Status will be Pending, indicating that the insurer hasn't yet set the benefit amount.
When the insurer sets the benefit the:

  • Benefit Amount is updated; and
  • Gap Claim Status is updated to Received; and
  • any notes from the insurer are recorded in the Benefit Notes

The customer can elect to:

  • pay the gap, i.e. the difference between the claim Total and and the Benefit Amount.
    The insurer will reimburse the practice to the value of the Benefit Amount.
  • pay the full claim.
    Here, the insurer will reimburse the customer.

When the claim is paid, the Gap Claim Status will be set to Paid, and finally to Notified, when the insurer is notified of the payment. This last step is required to allow the insurer to reimburse:

  • the practice, if a gap payment was made
  • the customer, if full payment was made
Invoices in Gap Claims

When making a gap claim, at least one invoice in the claim must be unpaid or part paid.

  • If the amount already paid on the included invoices is less than or equal to the gap amount, the
    payment requested will be the difference between the gap and the amount already allocated on
    the invoice.
  • If the amount already paid is greater than gap amount, then the difference will be refunded to the
    customer during the claim process.