It seems simple enough – you send a claim, insurance pays, and you receive the payment. But I think we can all agree that Insurance curveballs can have you striking out if you’re not on your A-game. In this post, we’ll discuss what to do when insurance pays on a different code than you billed, the best way to process single and batch claims, how to process partial or multiple claim payments, handling insurance overpayments, posting insurance interest payments, and more. You’ll be hitting it out of the park in no time!

Insurance Paid on a Different Code than You Billed

You’ve charted and completed bitewings (D0272 / D0273 / D0274) and a pano (D0330) for your patient, along with a few other procedure codes. You’ve submitted your claim, and you finally receive the insurance payment.

But they’re making it interesting for you again. They’ve paid based on a Full Mouth Xray (FMX) code (D0210) instead of the procedures you charted. Now what?

Here’s our recommendation.

1. You’ve charted and set complete the procedures that were done, so there is no need to delete these or re-chart anything else. It is fairly common for an insurance company to “remap” submitted codes to another code for payment purposes. That does not change the charted procedures that were determined by the dentist to meet the patient’s needs.
2. Allocate the insurance payment appropriately across the multiple codes you charted.
   If you’re receiving payment of $150 for the FMX and the charted Xray procedures are for $60 and $100 for example.
   TECH TIP:  Make sure to allocate payment accordingly so you don’t create an insurance over-payment on any one procedure code. To double-check, run the Insurance Overpaid Report.
3. Put a note in the “Remarks” column that the insurance paid based on FMX code D0210. This will leave a record of how insurance paid, and if needed, prompt a look at the EOB.
4. Finalize the payment as appropriate, scanning your EOB to attach it to the check.

Insurance Sent You a Payment (Yay!)

Depending on how insurance pays, you may need to receive the payment on the claim a little differently.

INSURANCE PAID ONE CLAIM IN FULL.

If you are entering a single claim payment, do this:

1. In the claim, receive the procedures by clicking By Procedure.
2. Enter the paid amount and write-off for each procedure, then click OK.
3. Click This Claim Only to finalize the payment, scanning to attach the EOB.

INSURANCE PAID ON MULTIPLE CLAIMS IN FULL.

If you are entering an insurance payment that pays for multiple patient claims, you have two options:

Record Payment in each patient’s account, repeat for each patient until done, then finalize:

1. Just like when processing a single patient claim, open the first claim, and click By Procedure.
2. Enter the paid amount and write-off for each procedure, then click OK.
3. Repeat steps 1 & 2 for each claim on the EOB.
4. Once you complete these steps for the final claim on the EOB, click Batch to finalize the payment.

or

Process a Batch Insurance Claim Payment:

1. In the Manage Module, click Batch Ins.
2. Click Add to create the check, then enter the payment information for the EOB.
3. Pick the Insurance Carrier, then click OK.
   
4. Search the Outstanding Claims list to find the needed claims.
5. Click Attach to immediately attach the claim to the check, or double-click the claim to make edits first.
   
6. Once all claims are attached, click Close to finalize the payment.

TECH TIP:  When you’re finalizing a batch claim and you attach the EOB, it can then be accessed from any patient on the check by going into their claim’s Insurance Payments area.

INSURANCE MADE A PARTIAL PAYMENT ON A CLAIM.

If insurance paid on only one or some of the procedures on a claim (and you are still expecting payment) do this:

1. In the claim, click on the procedures that were NOT paid.
2. Click the Split Claim button in the upper right.
3. These procedures will be split off onto their own claim with a status of “Sent” – this will maintain the visibility of this unpaid portion until you receive payment.
   TECH TIP:  By splitting the claim, the correct outstanding amount will continue to be visible in the Outstanding Insurance Claims Report.

INSURANCE MADE MULTIPLE PAYMENTS TO THE SAME CLAIM.

If insurance is making multiple payments on the same claim (e.g. Ortho payments) do the following:

1. Enter the first payment on the claim as normal.
2. For each subsequent payment, open the claim, highlight the paid procedures, then click Supplemental.
3. Enter the paid amount for each procedure.
4. Then click This Claim Only (if this is a single payment) or Batch (if this is part of a larger EOB) to finalize the payment.

INSURANCE OVERPAID ON A PROCEDURE (boo – more work for you…)

Insurance may do one of two things when an overpayment happens:

If insurance asks for a refund:

1. On the overpaid claim, create a negative supplemental payment for the overpaid amount (e.g. -100.00).
2. Click This Claim Only to create the refund check and finalize it. Ensure the amount is negative (e.g. -100.00) to show money is going back to insurance.

or

If insurance is allocating the refund to another patient:

1. On the patient with the overpayment, create a negative supplemental payment for the amount overpaid.
2. On the patient the money is being allocated to, create a positive supplemental payment for the amount.
3. Click Batch, then attach both supplemental payments to this check to finalize. This transfers the balance from one patient to the other.

Answers to some FAQs:

Insurance paid interest – how do I process this?
There are a few options – see them on our Interest on Insurance Payments manual page.

I sent the wrong procedures or the wrong provider was attached to procedures on a claim – what should I do?
Take a look at this manual page for the different scenarios and how to fix them.

I’ve heard about ERA835’s – are they a good option for my practice?
See our post on ERAs and What They Can Do For Your Practice. They can be a great time-saver!

What report will show me claims without payments?
The Outstanding Insurance Claims Report is what you’re looking for here. See our post: Tracking Revenue: Reports for Every Stage of the Cycle to make sure you’re running the reports you need to get a complete claims picture.

Need help troubleshooting any claim payment issues? Use Chat for a quick answer to a basic question, or call us if you need us to get remote-connected to review something in more detail. We’re here for you!