Insurance

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 or 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

 

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