The Claim Information block displays information that is specific to a patient and an insurance claim. Those items are numbered 27 through 35 on a standard ADA insurance claim form. The Standard information prints on the claim unless you have edited it.
Note: By default, "Standard" appears in the Claim Information block. If you have changed the standard information, "Non-Standard" appears.
To change medical claim information
1. Double-click the Claim Information block.
The Medical Insurance Claim Information dialog box appears.
2. Make changes to any of the information displayed in the Insurance Claim Information dialog box:
Type of Claim - Select the type of claim you are submitting.
Student Status - Select the appropriate status for the patient. If the patient is a part- or full-time student, enter the name of the school and the city where it is located.
Referring Physician - Click the search button to enter the referring physician. Then, in the ID Number Type list, select an ID number type. Add a second ID number if necessary.
Is Patient’s Condition Related To - Select the most appropriate option related to the patient’s condition, and type the state postal code. If treatment was necessary as result of an accident, type the relevant Date.
Attachments - Click to send attachments, such as letters, X-rays, and images, with an insurance claim.
Insurance Ref # - Type the insurance reference number.
Outside Lab? - Select and type the Charges for any lab work performed by a third-party.
Accept Assignment (Gov)? - Select to accept the assignment.
Dates Patient Unable to Work - Type the dates the patient was unable to work due to the illness or injury being treated.
Date of Current Illness or Injury - Type the date the current illness or injury occurred.
Related Hospitalization Dates - Type the dates for hospitalization as a result of the current illness or injury.
First Date of Same or Similar Illness/Injury - Type the date the same or a similar illness or injury occurred.
Original Ref. No - Type the original reference number.
Medicaid Resubmission Code - Type the appropriate Medicaid re-submission code.
Prior Authorization Number - Type the prior authorization number provided by the patient’s insurance carrier.
10d Reserved for Local Use - Type the appropriate local service code.
Name and Address of Facility where services were rendered - Type the name and address in the appropriate text boxes.
Note: Click Clear to reset the options to the default entries.
3. Click OK.
Note: When you enter or clear the claim information from a Claim window, the changes only apply to the currently displayed claim and the associated primary, secondary, or medical claim. When you create a new claim, the claim information uses the defaults for the current patient. You can change the defaults for the patient through the Appointment Book. For more information, see Scheduling appointments.