Insurance Claim

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
   

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

 

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