How to Create and Send a Pre-Authorization (Pre-Estimate) Insurance Claim

Need to send a pre-authorization (Pre-auth), predetermination (pre-D), or a pre-estimate claim to a patient's insurance company before treatment begins?

In Tops, you can create and submit a Pre-Estimate without activating the patient's Treatment Contract or starting treatment.

To send a pre-auth in Tops, create a Treatment Plan, record a Treatment Contract without charging the Initial Fee, and generate a Pre-Estimate Claim through Action > New Insurance Claim.

Follow the steps below to prepare and submit the claim.

Step 1: Prepare the Patient's Treatment Plan

1. Open the patient's chart.

2. Go to the Clinical side of the chart and select Dx/Tx Plan.

   Make sure the proposed Treatment Plan has been created and includes the following information required for insurance claims:

   • Dental Classification
   • Treatment Phase
   • Treatment Length

A Treatment Plan name is not required, but it is helpful when presenting multiple treatment options or selecting the correct plan for the pre-estimate.

Step 2: Record a Treatment Contract

Before generating the Pre-Estimate Claim, you must record a Treatment Contract associated with the proposed Treatment Plan.

1. Go to the Admin side of the patient's chart.
2. Select the Contracts/Ledgers tab.
3. Double-click No Contracts beneath the appropriate Treatment Plan.
4. Complete the contract worksheet using one of the following options.

Option 1: Without Accept Assignment

• Leave Accept Assignment unchecked.
• Enter the total contract amount.
• Calculate an Initial Fee, generally 25–35% of the contract value.
• Enter the expected number of months of treatment.

If the pre-estimate is approved: Before activating the contract, return to the contract worksheet, select Accept Assignment, and enter the expected insurance amount and patient's copay charges.

Option 2: With Accept Assignment

• Select Accept Assignment.
• On the left side of the worksheet, enter the total contract amount, an estimated Initial Fee (generally 25–35%), and the expected number of treatment months, including the anticipated insurance portion.
• On the right side, enter the expected insurance amount and the patient's estimated Initial Fee and monthly copay amounts.

If the pre-estimate is approved: Before activating the contract, review and update the worksheet with the patient's confirmed copayment amounts.

Important: Record the Contract Only!

Click Record. Do NOT charge the Initial Fee or activate the Treatment Contract.

The patient has not started treatment. You are recording the proposed financial information only so Tops can generate the Pre-Estimate Claim.

Step 3: Generate the Pre-Estimate Claim

1. From the patient's chart, go to Action > New Insurance Claim.
2. From the Claim Type dropdown, select Pre-Estimate Claim.
3. Select the Treatment Contract you just recorded.
4. Click Use Selected Contract.
5. Select the appropriate claim form, typically ADA 2019 Claim.
6. Enter any internal notes in the Notes field. These notes are only visible in Tops.
7. Enter any necessary remarks in the second Remarks field, which populates Box 35 of the claim.
8. Click Add New Claims to Tops.

Tops will generate the Pre-Estimate Claim, which can then be reviewed and submitted electronically or printed for mailing.

What If the Pre-Estimate Claim Is Rejected?

Some insurance payers require additional information, including a Treatment Start Date and the number of months of treatment, even when the patient has not yet started treatment.

If you receive a Clearinghouse Rejected error indicating that a start date or months of treatment are required, review the rejection and enter the required information.

For certain payers, such as Principal, the start date effectively serves as the request date and cannot be a future date.

Review the payer's requirements and correct the claim information before resubmitting.

When Pre-Authorization Is Required for an Insurance Claim

Some Employer Policies require a Pre-Authorization ID before a regular treatment claim can be submitted.

This is different from generating a Pre-Estimate Claim to request authorization before treatment begins.

If the Pre-Authorization Required option is selected in the Employer Policy record, Tops will prevent the associated claim for services rendered from appearing in the Unsent Ready to File filter of the Claims Matrix until the required information is entered. The claim will sit in Unsent Missing-Info Claims.

How to Enter a Pre-Authorization ID

Once the insurance company has provided the Pre-Authorization ID:

1. Open the Claims Matrix.

2. Select the Unsent Missing-Info Claims filter.

   

3. Locate the claim requiring the Pre-Authorization ID.

4. Right-click the claim and select Edit Claim.

   

5. Enter the Pre-Authorization/Pre-Determination Authorization Code:

   

6. Save the updated claim.

The claim should now appear in the Unsent Ready to File view, where it can be printed or e-filed.

Tops Tip: Pre-Estimate vs. Pre-Authorization ID

Need to request insurance authorization before treatment begins?

Generate a Pre-Estimate Claim using Action > New Insurance Claim > Pre-Estimate Claim.

Already received authorization and need to submit a treatment claim?

Enter the Pre-Authorization ID on the existing claim in the Claims Matrix.

These are two different steps in the insurance claim process!