Insurance

Complete

This screen displays the insurance policies and claims for the current patient.

The buttons are as follows:

  • New Policy
 Create a new Insurance Policy
  • Edit
 Edit the policy or claim
  • Delete

Delete the selected policy or claim.
Policies that have been claimed, or claims that have been submitted cannot be deleted.
  • Claim
 Make a new claim
  • Submit
 Submit a claim to the insurer. Once submitted, the claim cannot be changed.
  • Pay Claim
 Pays a gap claim.
  • Cancel Claim
 Cancels the selected claim.
  • Settle Claim
 Mark a claim as being settled by the insurer.
  • Decline Claim
 Mark a claim as being declined by the insurer.
  • Print
 Print the selected claim.
  • Mail
 Email the selected claim.

Gap Claim Payment

If a claim has its Gap Claim flag ticked, it is a gap claim.
When submitted to the insurer, the insurer will determine the benefit amount, and the customer can either pay the gap, or the full amount.

Gap claims can only be paid after the claim has been submitted to the insurer i.e., the the Claim Status must be Submitted or Accepted.

If the insurer hasn't yet determined a benefit amount for the claim, a Waiting for Claim Benefit window will be displayed. This will monitor the claim, until the insurer notifies of a benefit amount. When this occurs, the Gap Claim Status changes to Received.
It may take the insurer some time to determine the benefit amount. Clicking:

  • Pay Full Claim
 prompts to pay the full claim amount. The insurer will reimburse the customer.
This option is only available once the insurer has accepted the claim i.e. the Claim Status is Accepted.
  • Cancel
 stops monitoring the claim.
To restart monitoring, click Pay Claim again.

When a benefit amount has been determined, a Pay Claim window will be displayed. This shows the:

  • Claim Total
 the total being claimed
  • Agreed Benefit
 the amount the insurer has agreed to cover
  • Gap
 the difference between the Claim Total and Agreed Benefit
  • Paid
 the amount already paid

If nothing has been paid, or the amount already paid is less than or equal to the gap, the customer can elect to pay either the gap or the full claim.
If the customer has paid more than the gap, the customer must pay the full claim.

Selecting:

  • Gap
 a payment window will be displayed to collect payment up to the gap amount. On completion, a Credit Adjustment will be created, for the Benefit Amount.
  • Full  Claim
 a payment window will be display to collect payment to the claim total.

Once payment is made, the insurer will be notified. This enables them to reimburse the:

  • practice, if a gap payment was made
  • customer, if full payment was made

 

Create/Edit Insurance Policy

Complete

This is the screen used to create or edit an insurance policy for a patient.

The fields are as follows:

Policy Number the policy number assigned to the policy by the insurer
Start Date the date the policy starts on
End Date the date the policy ends on. Optional.
If set, the policy cannot be claimed against after the specified date.
Customer the customer the policy belongs to
Insurer the insurance provider
Author the user that created the policy

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.
When making a gap claim, all of the invoices in the claim must be unpaid.

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