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 and, on some drafts, Correct prior payer figures — carry the actions; hover one for its name. If the claims can't be read, the table says so with Retry rather than showing an empty list.

Before the first claim

Two identities travel on every claim:

• The billing provider: your practice's legal entity, with its billing NPI, tax id and taxonomy, kept under Settings → Insurance benefits → Claims billing identity (or under Legal entities in Settings → Practice details).
• The treating clinician: their first name, last name, specialty and NPI, kept under Legal name on their row in Settings → Practitioners.

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, down to the clinician's missing name, specialty or NPI.

A claim names the clinician by the registration in force when it is sent: correct a name, specialty or NPI under Settings → Practitioners and the next Send or Resend carries it. A claim already sent keeps what it was sent with.

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.

An erased patient's kept claim still goes out and is still paid, but none of these tasks — nor a remittance line's, below — is opened for it: the same work waits for the owner in the review queue, naming no one.

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 under Payments → Claims 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, and choose the new status. The event is the record: the claim's status and totals follow from it and cannot be edited directly.

• Accepted, Rejected, Pending information, Received, Settled and Void only move the claim.
• Paid, Partially paid and Denied are the payer's answer, entered per procedure exactly as the EOB states it: one line for each procedure on the claim, with what the payer paid, what it allowed (optional), and every adjustment with its group (CO, CR, OA, PI or PR), reason code and amount. Every amount is typed as the EOB shows it — 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. A line that does not is refused before anything is sent. A denial with no amounts leaves every line blank: each procedure is then answered with nothing paid, so the estimate stops counting on that payer, and a secondary claim tells the next payer the claim was denied.
• An interim payment — money the payer paid before it decided the claim — is Received with Interim payment ticked, entered per procedure the same way. The claim stays received and its treatments wait for the payer's decision.

An adjustment the EOB states for the claim as a whole, rather than on a procedure's line, goes under Claim-level adjustments — click Add adjustment there and enter its group, reason code and amount. Claim-level adjustments reduce what the payer paid on the claim: two lines paid $80 each with a claim-level CO-45 of $5 is a $155 payment. Payment on the claim shows that figure as you type — the lines' payments less the claim-level adjustments — and claim-level adjustments that take more than the lines paid are refused before anything is sent. A denial whose lines you leave blank can still carry its claim-level adjustments: the payer paid nothing.

For a denial, add the payer's Denial codes from the EOB, separated by commas or spaces (for example CO-50, N130) — up to 20 codes of up to 20 characters each.

Add the Check or EFT number from the EOB. The same payment with the same contents, entered again or arriving later on an electronic remittance, is then recognised and posts nothing twice.

The payment posts to the patient's account against the claim's charges. The plan's own contractual write-off — its fee schedule (CO-45) or capitation (CO-24) adjustment — posts as an insurance write-off on the legal entity that billed the claim. Any other adjustment is not written off on its own: it waits for a decision on the claim. The PR rows are the patient's.

A claim that already has an answer asks first: "This claim already has an answer. Add this one to it?" Click Add this answer to post it beside the earlier one — a later payment or a supplement — or Cancel to go back to the form. Retrying after a lost connection never posts the same answer twice. A void claim takes no money, and voiding a claim frees its treatments for a new claim.

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. The figures are read again from the payers' answers each time the claim is sent, so an answer the payer corrected is sent as corrected, and a discount a later answer repeats is sent once; each submission keeps the figures it was sent with. A secondary cannot be sent before the primary has answered; a tertiary needs the secondary's answer too. Sending is also refused while an answer on an earlier claim is held for review, or waits for a decision on its write-off, and the message says which.

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, CR correction or reversal, OA other, PI payer initiated, PR patient responsibility), 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.

Correct the prior payers' figures

While such a claim is still a draft, its row shows Correct prior payer figures. Click it to open the prior payers' EOB figures as they were last entered — the dialog names the patient and their date of birth and says which revision is on file — change what the EOB says, and click Save. Each line must still balance against what the claim bills for it, exactly as when the claim was built; a line that does not is refused before anything is saved. What the dialog does not show is kept exactly as the revision on file has it: the subscriber's benefit-assignment and release indicators, any adjustment to the claim as a whole, and the code, units and date the payer gave each line. The patient's share the payer stated — for each line and for the claim, a zero included — is kept too, and worked out again from the PR rows only for a line whose paid amount or adjustments you change. Correcting one figure changes only that figure.

Every save is kept as a new revision, and the earlier ones stay on record; the claim sends the latest. Once the claim has been sent, its prior payers' figures are what it was sent with and can no longer be corrected. A claim whose prior payer's figures come from a claim Smileline sent does not offer this: those figures come from that claim's own answer.

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. The check goes to the payer through the clearinghouse and is answered within the minute. Click Eligibility history beside Insurance to see every check with the payer's answer — see Eligibility history.

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, 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. The plan's own contractual write-off — its fee schedule (CO-45) or capitation (CO-24) — posts as an insurance write-off on the legal entity that billed the claim, once per treatment however many answers repeat it; for a secondary payer, only what it writes off beyond the primary. Any other adjustment is not written off on its own: it waits for a decision on the claim. 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 claim's payment that cannot post on its own is held whole, with what the payer said, and a task — a second answer for a claim that already has one, a payment with a line the claim has no item for (or a line without our control number when two items share its code and service date — two teeth, say), a payment its lines and adjustments do not explain, or one for a void claim. Nothing is posted against a guessed item, and the rest of the file still posts. The same payment arriving again with the same contents is recognised as already posted: it is kept on the claim and posts nothing, with no task. 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.

When the payer takes a payment back

A payer that corrects a claim it has already answered sends, on an electronic remittance, a take-back of its earlier answer (claim status 22, a reversal), usually followed by the corrected payment. When the take-back states exactly what one answer on the claim stated — the same procedures, every amount reversed, under the same payer claim number — Smileline reverses that answer on its own: its insurance payment and its insurance write-off come off the patient's account together, with everything decided from that answer.

• When it was the payer's only answer on the claim, the claim goes back to Received, and the corrected payment then posts as the claim's answer, with its own payment and write-off, whether it arrives in the same remittance or a later one. No secondary claim can be sent while the claim waits for the correction, and one sent after it carries the corrected figures only.
• When another answer from the payer still stands — a later payment it added, say — the claim keeps that answer's status, and the corrected payment is held on the claim for review like any other second answer.

A take-back that does not match exactly one answer is held on the claim with what the payer said, and a task, and nothing is reversed: one that matches no answer or more than one, takes back only part of an answer or different amounts, or takes back a payment you have already refunded part of to the insurer. The same take-back arriving again is recognised and changes nothing.