If you submit dental insurance claims through eClaims, which is the electronic claims service that is provided by Henry Schein One, you can also submit medical insurance claims through eClaims.
Notes:
The Centers for Medicare and Medicaid Services (CMS) was formerly known as the Health Care Financing Administration (HCFA). The CMS-1500 (HCFA 1500) and CMS-1450 (UB-04) forms are standard AMA claim forms.
With HCFA or HCFA212 selected as the Claim Format, you can print claim information on a pre-printed CMS-1500 form (not a blank piece of paper) using a laser or inkjet printer, or you can send a claim electronically as an 837p file.
837p files (electronic versions of the paper form CMS-1500) are used to transmit professional claims. Professional claims are those submitted by physicians, suppliers, and other non-institutional providers for either inpatient or outpatient services.
With UB04 selected as the Claim Format, you can print claim information on a pre-printed CMS-1450 form (not a blank piece of paper) using a laser or inkjet printer.
837i files (electronic versions of the paper form CMS-1450) are used to transmit institutional claims. Institutional claims are those submitted by hospitals and skilled nursing facilities. Currently, sending institutional medical claims electronically as 837i files is not supported.
For the successful transmission of medical insurance claims, make sure that the required information is set up in the following areas of Dentrix Enterprise:
Clinic Information - Verify the following clinic information for each clinic where services are rendered:
Clinic TIN.
Title.
Address (street, city, state, and ZIP Code).
Billing Provider Information - Verify the following provider information for each billing provider:
Name.
Specialty.
Address (street, city, state, and ZIP Code).
Phone.
TIN #.
NPI.
Rendering Provider Information - Verify the following provider information for each provider who renders services:
Name.
Specialty.
Address (street, city, state, and ZIP Code).
Phone.
State ID.
NPI.
Pay-To Provider Information - Verify the following provider information for each pay-to provider:
Address (street, city, state, and ZIP Code).
Medical Insurance Plan Information - Verify the following plan information for each medical insurance plan that is attached to a patient:
Carrier Name.
Group Plan (optional if Group # is present).
Address (street, city, state, and ZIP Code).
Group #.
Claim Format - For professional claims (837p files), HCFA or HCFA212 must be selected. For institutional claims (837i files), UB04 must be selected.
837i - For institutional claims (837i files), this checkbox must be selected.
Payor ID (optional if Group Plan is present).
Note: If blank, the default Provider ID will be used on the claim form.
Source of payment - [None] must not be selected.
Diagnostic Code System - ICD 9 or ICD 10 must be selected.
Advanced (optional claim settings).
Patient - Verify the following subscriber information for each medical insurance plan that is attached to a patient:
Medical Insurance Plan.
Subscriber Id #.
Procedure code - Verify that each procedure code that will be billed to medical insurance can be cross coded:
Flag for Medical Cross Coding - This checkbox must be selected.
Medical cross coding - Verify that medical codes are entered and cross coding is complete:
On the Code Setup tab, the necessary medical codes must exist (AMA, modifiers, place of service, type of service, ICD-10, and ICD-9).
On the Cross Code Setup tab, medical cross coding must be done (AMA with ICD-9, AMA with ICD-10, and CDT with AMA).
Note: Whether ICD-9 or ICD-10 codes are accepted on medical insurance claims depends on the selected Diagnostic Code System option for the corresponding medical insurance plan.
With all applicable setup complete, do the following to process medical insurance claims:
Cross code the procedure for medical billing.
Create a primary medical insurance claim for the procedure.
Edit the claim as needed:
Change the standard claim information (such as adding a referring physician, adding accident information, and entering a pre-authorization number).
Include attachments with the claim.
Sort the diagnostic codes on the claim.
Either submit the claim in Ledger, or submit the claim in Office Manager.