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

The following options are available, based on how much the customer has already paid towards the claim:

  • Pay Gap
Make a Gap claim.
This option is available when the amount already paid towards the claim is less than the Gap.
  1. A payment window will be displayed to collect payment up to the Gap amount.
  2. A second Payment will be created, for the Benefit Amount in the Practice Location's Gap Benefit Till.
  3. The insurer will be notified of the Gap payment
  • Refund and confirm Gap Payment

Make a Gap claim.
This option is available when the amount already p
aid towards the claim is greater than the Gap.

  1. The customer will be refunded the difference between the paid amount and the Gap.
  2. A Payment will be created, for the Benefit Amount in the Practice Location's Gap Benefit Till
  3. The insurer will be notified of the Gap payment
  • Pay Full  Claim

Make a standard claim. i.e. the customer will pay the full claim amount and be reimbursed by the insurer.

  1. A payment window will be displayed to collect payment up to the claim amount, if payment has not already been made.
  2. The insurer will be notified of the full payment
  • Confirm Gap payment

Make a Gap claim.
This option is available when the amount already paid towards the claim is greater than the Gap,  but less than the full claim amount. This should be selected when submitting multiple claims for a customer where a deposit has been collected. It doesn't 
create a Refund.

  1. A Payment will be created, for the Benefit Amount in the Practice Location's Gap Benefit Till.
  2. The insurer will be notified of the Gap payment

The insurer will be notified to enable them to reimburse the:

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

 

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