Insurance claims

Claims sits under the Insurance section of the Account tab on the clinical record: a table of every claim with its status, kind and billed total, when it was sent or created, the payer's reference and what has been paid. The row's icons — Send or Resend, Claim secondary, Record outcome, Attach — carry the actions; hover one for its name.

Before the first claim

Two identities travel on every claim:

• The practice's billing NPI, tax id and taxonomy, kept under Settings → Insurance benefits → Claims billing identity.
• Each dentist's NPI, kept on the practitioner's identifiers.

Each carrier needs its payer id on the Insurance carriers page. Claims queue only when all three are on file; the page says which is missing.

Build a claim

Click the + icon beside Claims. The dialog lists completed procedures with a CDT code that no open claim carries, all ticked. Untick any to leave for another claim, choose Claim or Predetermination, add ICD-10 diagnosis codes if the payer wants them, and click Create claim.

One claim carries one dentist at one location; split the procedures otherwise. The claim opens as a draft with its items priced from the procedures' fees and the insurance estimate stamped on them. A procedure recorded with a quantity is claimed at that many units: the item carries the units, its billed amount is the fee times the units, exactly as the ledger charged it, and the 837D line names the same count.

Send it

Click the row's Send icon. Smileline writes the 837D as a submission, queues the claim and, within the minute, carries it to the clearinghouse. The claim moves to Sent when the clearinghouse accepts it, or Rejected with the reasons when it refuses the payload. Fix the cause and click Resend: that is a new submission generation on the same claim.

A clearinghouse outage never loses a claim. The attempt parks, a task tells the desk, and the lane retries on its own with a growing pause. Open the claim to see every attempt. One thing stops the retries: a claim that first went out more than 24 hours ago and has still not been accepted. Sending it again after that could file it twice, so the attempt parks for reconciliation and a task asks the desk to check with the clearinghouse whether the claim arrived — record the outcome on the claim, or record it rejected and click Resend.

Two answers follow a sent claim: the interchange acknowledgement (a 999) within hours, then the payer's acceptance (a 277CA). A 999 that refuses the file moves the claim to Rejected with the syntax codes in its history, exactly as a refusing 277CA does; fix the cause and Resend. A sent claim that has heard nothing after three days appears on the Unacknowledged claims worklist so it is chased before the payer's timely-filing clock runs out; nothing is cancelled on your behalf.

Record an outcome

Click Record outcome to move the claim from what a paper EOB, a payer portal or a phone call told you: accepted, pending information, received, paid, partially paid, denied, settled or void. Enter the paid, allowed and written-off amounts as the payer reports them; they add to the claim's totals. The event is the record: the claim's status and totals follow from it and cannot be edited directly.

Secondary and tertiary claims

A patient with more than one cover is claimed one payer at a time, in claim order: the primary first, then — once the primary has answered — the secondary, and the tertiary after that. The next payer's claim carries what the payers before it did, so it is built from the answered claim rather than from scratch.

Once a claim has a posted remittance (paid, partially paid or denied — a denial still counts as the primary's answer), its row shows Claim secondary; on an answered secondary it shows Claim tertiary. Click it and Smileline opens a draft on the cover at the next claim order with the same procedures, place of treatment and diagnoses as the answered claim. It always carries every procedure of that claim: the prior payer's figures balance only across the whole claim it answered, so a claim built on a subset of its items is refused. A procedure sits on the primary's claim and on the secondary's at the same time; each cover carries it once. The draft shows Secondary or Tertiary beside its status and, when opened, which payers came before it and what they paid.

When the draft is sent, the 837D names the prior payer and the subscriber exactly as they stood on the claim that payer answered — not as the cover reads today — with the payer's claim number, what it paid at claim level and on each line, every adjustment it stated with its group and reason, the adjudication date and the patient's remaining liability. These figures are frozen with the submission: resending re-reads the record and keeps a new revision only when something changed. A secondary cannot be sent before the primary's remittance has posted; a tertiary needs the secondary's.

When the primary was not sent through Smileline

If the primary claim went out on paper or from another system, tick The primary claim was not sent through Smileline in the New claim dialog. Choose the cover at claim order 2 (or 3) — the list offers the covers in force on the service dates of the procedures you ticked, whether or not they have since ended — then enter each prior payer's EOB: the payer id and name, its claim number and adjudication date, the subscriber's name, member and group numbers and relationship, and for each procedure what the payer paid and every adjustment the EOB states, each with its group (CO contractual, PR patient responsibility, OA other, PI payer initiated), its reason code and its amount. Every amount is typed as the EOB shows it — nothing is assumed, and a blank or unreadable amount is an error rather than zero — and each line must balance as the payer balanced it: the fee equals the amount paid plus the adjustments. The PR rows are what the next payer is told the patient still owes. A tertiary claim takes two prior payers, the primary first. The procedures already on a Smileline primary are offered again for the cover you chose.

Attach documents

Click the Attach icon to add a radiograph, perio chart, narrative or photo from the patient's documents, naming what the payer asked for and the NEA number if you sent it that way.

Tick Attachments required before sending on a claim the payer will not adjudicate without them: Send then refuses until at least one document is attached, and the open claim warns while none is. Each attachment travels on the 837D as a report entry — a radiograph, perio chart, narrative, photo or EOB by type, sent electronically under its NEA number when you gave one, otherwise marked on file and available on request. The 837D carries at most ten such entries; a claim with more sends the ten most recent and keeps the rest on file.

Check eligibility

On an open coverage in the Insurance section, click the Check eligibility icon. A clearinghouse check is answered within the minute and listed under the coverage; a manual check records what the payer said on the phone or in its portal.

Open a claim

Click the claim's title to see its items with estimates and payments, its full history, every submission with each delivery attempt and the clearinghouse's references, its attachments, and — on a secondary or tertiary — the prior payers and what they paid.

Electronic remittances

When the clearinghouse is connected, the payer's answers arrive on their own. A claim acknowledgement (277CA) moves the claim to Accepted or Rejected with the payer's status codes. An electronic remittance (835) posts the payer's payment for each claim as one insurance payment on the patient's account, allocated to the claim's own charges first, and moves the claim to Paid, Partially paid or Denied with the allowed, paid and written-off amounts and the payer's claim number. The claim's paid amount is what the payer says it paid for the claim, which its lines and any claim-level adjustments must explain (a line paid 80.00 with a 5.00 contractual adjustment at claim level is a claim paid 75.00); each line keeps its own paid amount. Each adjustment is kept with its group and reason code: only contractual (CO) adjustments count as written off, each item's patient portion is the patient-responsibility (PR) adjustments on its own line, and the claim-level patient responsibility and any claim-level adjustments are recorded on the claim's history. The units the payer adjudicated on each line are stored beside it. A remittance that pays claims from several practices reaches each practice with only its own lines and its own total — what the payer paid for that practice's claims, never the file's total — and a remittance file carrying several payments is recorded as one remittance per payment. A line that names the practice's claim but cannot be posted (an item the claim does not have, a claim already settled, or a line without our control number when two items share its code and service date — two teeth, say) parks with a task so the desk can post it by hand from the claim, never against a guessed item; so does every line of a claim whose payment its lines and adjustments do not explain. A line that names no claim of any practice, and any money in the file that no practice's claim payments account for, is held for Smileline's review with the file's total and never appears in a practice. The same holds for an acknowledgement or remittance that names no claim Smileline knows, one that names a claim Smileline knows beside one it does not (it stays held until every claim it names is resolved), a 999 that carries no acknowledgement code Smileline recognises, or a report that arrives in a shape it cannot read: it is held for review, never acknowledged and forgotten. Nothing a payer sends is ever dropped.