Generate a Pre-Estimate Claim
Your patient wants you to send a pre-estimate to their insurance. How can you do this when they have not yet begun treatment? We've got you!
- Open the patient chart.
- Make sure that the patient's treatment plan has been set up in the Dx/Tx Plan section in their Clinical chart. For claims purposes, you must fill in Dental Classification, Treatment Phase, and Treatment Length. A Treatment Plan name is not required but is helpful:
- Next, go to the Admin side of the patient chart and click on the Contracts/Ledgers tab.
- Double-click on No Contracts under the treatment plan you created (this is why the Treatment Plan name is handy, in case you prepared more than one treatment option.)
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Option 1: Enter the contract information without selecting “Accept Assignment.” Enter the total contract amount. For the initial fee, calculate 25–35% of the contract value. For the number of months, enter the expected length of treatment.
If the pre-estimate is approved, before initiating the contract, remember to edit the contract worksheet by selecting “Accept Assignment” and entering the expected insurance amount along with the patient’s copay charges.
Option 2: Enter the contract information and select the “Accept Assignment” box. On the left-hand side, enter the total contract amount. For the initial fee, calculate 25–35% of the contract value. For the number of months, enter the expected length of treatment, including the expected insurance amount, just as you would if the patient were starting treatment.
On the right-hand side, enter the expected insurance amount, as well as the estimated patient initial fee and monthly payment amounts.
If the pre-estimate is approved, before initiating the contract, remember to edit the contract worksheet and update the details with the patient’s copayment amounts.
- Record the contract only; do not charge the Initial Fee.
- Go to Action > New Insurance Claim and select the Pre-Estimate Claim claim type from the dropdown.
- Select the contract that you just recorded and click Use Selected Contract.
- Select a claim form (typically ADA 2019 Claim) and enter Remarks (reflected in Box 35), if needed (the second field).
- Click Add New Claims to Tops.
- Tops will generate the Pre-Estimate Claim for e-filing or mailing.
Note: If you receive a Clearinghouse Rejected error upon submitting the pre-estimate noting that a start date and months of treatment are required, you will need to enter the required information to resolve the rejection. There are some payers (i.e. Principal) that require you have a start date and months of treatment entered. The start date essentially becomes the "request date" and cannot be a date in the future.
When Pre-Authorization is required
Some employer policies require you to identify the pre-authorization ID on the claim.
Checking the box in the employer policy stops the claim from appearing in the Claims Matrix in the Unsent Ready to File filter until you have received confirmation.
Locate the claim in your Unsent Missing-Info Claims.
Locate the claim, right-click and select Edit Claim.
Enter the Pre-Authorization ID
The claim should now appear in the Unsent Ready to File view and can be printed or e-filed.