Claims Matrix FAQs

Visit Matrix > Claims for a comprehensive view of your claims.

Visit this report daily to e-File or print claims, address unpaid claims, and to find claims needing more information. Here are some commonly asked questions about the Tops Ortho Claims Matrix.

What is the Claims Matrix?

The Claims Matrix is a centralized view of insurance claims in Tops and is most commonly used to manage open claims. While claims can be searched and reviewed by status (Submission Type, Open, Closed, Voided), date range, or other criteria, most practices use the Claims Matrix to:

• Review claims that are open and awaiting payment
• Identify claims that need to be manually filed or electronically submitted
• Monitor claims that require attention due to missing information or submission issues
• Track aging claims and follow up on outstanding insurance payments

Claims are generated based on qualifying posted ledger activity and the settings configured within the patient’s Employer Policy. Qualifying transactions are ledger transactions that have been designated to appear on claims and may include contract charges, treatment fees, and other insurance-billable transactions.

The Employer Policy determines when and how claims are generated through settings such as claim frequency, claim type, and payment calculation.

For example, if an Employer Policy is configured with a Quarterly claim frequency and a next claim date of 4/1/2026, Tops will review qualifying ledger activity posted since the last claim period and generate a claim containing those transactions. These transactions may include automatically posted contract charges as well as manually posted fees that have been designated to appear on claims.

Why don't all open claims reflect a payment value?

A claim’s Possible Payment value is determined by the patient’s remaining policy benefit and the payment calculation configured within the Employer Policy. As a result, not all open claims will display a payment value.

A claim may not display a Possible Payment value, or may display a value of $0, for any of the following reasons:

• The patient’s remaining benefit has already been allocated to older open claims.
• The patient has no remaining benefit available on the policy.
• The claim is a manually generated date-range claim, which is not assigned a Possible Payment value.
• The claim is more than 120 days old. Possible Payment values are displayed only for claims within the 0-120 day aging period.
• No payment percentage has been configured in the Employer Policy, causing the claim to display a question mark (?) or no value.

Claims older than 120 days may still have benefit amounts reserved against them even though no Possible Payment value is displayed in the Claims Matrix. Any benefit previously allocated to an older open claim continues to be considered when calculating Possible Payment values for newer claims.

For example, if a patient has $400 in remaining policy benefits, a 50% payment calculation, and five open claims with $200 of eligible charges each, the system will allocate the available benefit starting with the oldest claim. The first four claims will each reflect a $100 Possible Payment value, while the fifth claim will display $0 because the available benefit has already been allocated to the older claims.

If one or more of those older claims are more than 120 days old, their Possible Payment values will no longer be displayed in the Claims Matrix. However, the associated benefits remain reserved for those claims and are therefore unavailable to newer claims.

It is important to remember that Possible Payment values are based on the Employer Policy’s remaining benefit and payment calculation, not the patient’s Expected Insurance balance.

My claim is more than 120 days old. Why is there not a value represented?

Tops will only show an estimated payment value with an open claim if the claim is between 0 and 120 days old. The age of the claim is based on the claim generate date, the first date represented in the claims matrix.

• Please read the section below titled Claims with Payment Values.

My claim is less than 120 days old. Why is there not a value represented?

• Date range claims do not display estimated payment values.
• The patient may not have a remaining benefit left to calculate a possible payment.  Please read the section below titled Claims with Payment Values.

Why can't I see my Unpaid Claims?

• Don't worry; you still can! When you select the Unpaid Claims filter in the Claims Matrix, Tops Ortho defaults to showing you the claims in Rejected by Clearing House status. This is because these claims require your prompt attention.
• To see all of your Unpaid Claims, set the filters from left to right to:
  • Unpaid Claims
  • All Offices (or the office of your choice)
  • All Submission Values
  • Open Claims Only

What do the symbols in the second column mean?

These are indicators of claim type:

• A dot indicates an Initial Claim
• A diamond indicates a Pre-Estimate/Pre-Determination Claim
• No indicator present indicates a Periodic or Date-range Claim.

What do the yellow caution signs in the third column mean?

• The yellow caution sign will appear when the claim contains missing or incorrect information.
• Hover over the yellow caution sign to learn more about the missing/incorrect information.
• See related articles EClaims with Rejected by Clearing House Status and Common eClaim Rejection Reasons for more details.

Can I view this report by Insurance Company?

• Yes! Simply click the up/down arrow icon on the Employer heading and select Insurance instead.

• Click the Insurance heading to group Insurers together.

  

What information pulls in the Notes column?

• This column displays what is typed in the Internal Notes for this Claim field.
• To view or edit this field, right-click on the claim and select Edit Claim.

Why does my claim's aging reflect a question mark (?) ?

If a claim payment value reflects a question mark, it is due to the Employer Policy missing the payment percentage.

Why do I not see ALL of my claims that are over 30 days old in the Delinquent Claims view?

All open claims that appear in the Delinquent Claims view will also appear in Unpaid Claims view with the Open Claims Only  filter selected.   The reverse is not true. All claims over 30 days old in the Unpaid Claims>Open Claims Only view do not appear in the Delinquent Claims view.

Claims in the matrix are aged by generation date in the following ranges: 0 to 30, 30 to 60, 60 to 90, and Due 90+  (Due 90+ representing the final range of 90-120 days).

The Delinquent Claims view provides visibility to only those claims that meet the following requirement:

• The claim is between 31 and 120 days old.
• The claim displays a possible payment value.
  • The payment value displayed for a claim is based on the benefits remaining on the patient’s policy. Tops first allocates any available benefits to older, open claims, regardless of age. If benefits remain after those claims are considered, Tops applies the employer policy’s payment percentage to calculate the estimated payment amount for the current claim and displays the remaining benefit available to pay that claim.
• Claims that remain open beyond 120 days will still appear in the Unpaid Claims Matrix under Open Claims Only, but no longer will display a possible payment value or appear on the Delinquent Claims list.

Why did a new claim appear or disappear on my Delinquent Claims view?

New Claim Appeared

Tops calculates potential payment values by applying the remaining benefits available on the policy to open claims, starting with the oldest claim first.

In some cases, an older claim may consume all available remaining benefits when Tops calculates potential payment values. As a result, newer claims may not display any payment value because no benefits remain available for them.

Once a payment is posted to that older claim, the claim is closed and no longer reserves its previously calculated payment value. TOPS then recalculates the remaining benefits available on the policy and applies them to the next oldest open claims.

If one of those claims now calculates a potential payment value and falls within the Delinquent Claims criteria (older than 30 days but not older than 120 days), it will appear on the Delinquent Claims view.

In short, posting a payment to an older claim can free up available benefits for other open claims, causing those claims to calculate a payment value and become visible on the Delinquent Claims report.

Existing Claim Dropped off List

When a claim is "matched" with an insurance payment, the status will update to "paid" and it no longer remains open. If it was on the Delinquent list, it will now no longer appear.

Additionally, if a claim ages out of the Delinquent Claims list, it means the claim is older than 120 days old.  The claim will drop off the Delinquent Claims list but still appear in your Unpaid Claims>Open Claims Only view.

What is the difference between the two views, Delinquent Claims and Unpaid Claims>Open Claims Only? How should they be utilized?

All open claims that appear in the Delinquent Claims view will also appear in Unpaid Claims view with the Open Claims Only  filter selected.   The reverse is not true. All claims over 30 days old in the Unpaid Claims>Open Claims Only view do not appear in the Delinquent Claims view.

The Open Claims Only filter of Unpaid Claims is the best option when:

• You have claims that may be older than 120 days.
• You are cleaning up a congested Claims Matrix containing old or unnecessary claims.
• You want to review all open claims regardless of age or calculated payment value.

The Delinquent Claims view is most effective when your practice actively manages all open claims and has few or no open claims older than 120 days. Because claims older than 120 days are excluded from this view, practices with a significant number of older open claims should use Unpaid Claims>Open Claims Only  to ensure no outstanding claims are overlooked.

Should Expected Insurance match Claims Matrix totals?

No. Expected Insurance and the Claims Matrix are calculated differently, so the totals are not intended to match.

Expected Insurance is calculated from ledger activity, making it a ledger-based value. It is not directly tied to individual claims or to the Claims Matrix.

The Claims Matrix, on the other hand, is claim-based. It is driven by employer policy calculations, remaining policy benefits, and existing open claims rather than ledger balances.

Because these calculations are fundamentally different, the totals will not reconcile and should not be expected to match.

Continue reading for a more in-depth understanding.

Expected Insurance in the Accounts Receivable report represents the portion of a patient’s total balance that is anticipated to be paid by insurance. The Expected Insurance amount displayed in the A/R report is the same Expected Insurance value displayed within the patient’s chart. This amount is derived directly from the patient’s ledger and helps determine how the total balance is distributed across Due Now, Future Due, Copay, and Expected Insurance.

Expected Insurance is not a static value. It will fluctuate over time based on ledger activity, including the initial contract setup, where a portion of the total fee is designated as expected insurance; insurance payments posted to the patient’s ledger; and any manual adjustments made through Action > Change Expected Insurance.

Because Expected Insurance is calculated from ledger activity, it is a ledger-based value and is not directly tied to individual claims or Claims Matrix totals.

Changes made to Expected Insurance do not impact the remaining benefit on an employer policy, nor do they affect the amount represented on any open claim. Likewise, adjusting a policy’s remaining benefit, closing a claim, or voiding a claim does not affect the patient’s Expected Insurance balance.

The primary point where these two systems intersect is when an insurance payment is posted. Posting an insurance payment reduces the patient’s Expected Insurance balance on the ledger and also reduces the remaining benefit available on the policy associated with that payment. Outside of posted insurance payments, Expected Insurance and policy/claim calculations operate independently of one another.