How to Handle Partial Insurance Payments

Insurance companies are becoming more and more particular about the type of attachments and documentation they require to process a claim. For example, I was in an office recently that had submitted a claim for a crown with a periapical film. Typically, this type of x-ray would be adequate, but the insurance company sent an explanation of benefits back to the office stating that to process a claim for a crown, the office must submit both a periapical film and a bitewing x-ray.

These types of situation happen daily. Sometimes, when you send an insurance claim for a crown and a crown build-up, the insurance company may pay for the crown build-up, but not the actual crown until additional information has been received. If the insurance company is paying for one procedure now and waiting on additional information before it pays for the second procedure, you should post the payment for the crown build-up when it’s received and not hold the payment until all the procedures have been considered.

When this happens, you want to keep the crown procedure as an outstanding claim to the insurance for two reasons: 1) you can continue to track the outstanding insurance claim for the crown using the Insurance Aging Report in the Dentrix Office Manager, and 2) if you were to post the payment for the build-up and post a $0 payment to the crown, the patient’s ledger would reflect a larger patient portion of the balance than is actually due.

Dentrix has a solution for these types of situations. When you receive a partial payment for an insurance claim, split the primary claim to post payment to the paid procedures and leave the procedure that requires more information as an outstanding claim.

There are a couple of advantages to splitting the claim:

1. If you were to post the payment for the build-up procedure, but post to a $0 payment for the crown, the entire claim would then be closed. It will no longer appear on the Insurance Aging Report, so you lose the ability to track it and it could easily slip through the cracks. By splitting the claim, you are still able to track it.
2. Splitting the claim keeps the original narrative in the remarks for unusual services. You may need to refer to the narrative on the original claim if you have to appeal the claim, and by having a record of the original narrative you’ll know what you wrote and what information you may need to add if further action is required by the office. 
3. The original sent date will be accurate, and any claim status notes you made on the claim will remain with the claim. I wrote a blog post in August about the value of using insurance claim status notes. Once you’ve spent time tracking insurance claims and making notes, you would want to ensure those notes are saved.

To split a primary claim, open the patient’s Ledger. Click once on the claim you want to split so it is highlighted. Then select Insurance > Split Primary Claim.  Select the procedure(s) to be moved to the new claim, then click the down arrow to move it to a second claim.

Once the procedures are split into individual claims, you can post payments to the claims as you normally would.

The ability to split insurance claims is a feature that I find particularly useful that many offices aren’t aware of. Splitting claims helps to keep accurate claim tracking during times when insurance companies request additional information.  If you have questions on this or another topic, please e-mail me at

from  The Dentrix Office Manager Blog https://ift.tt/2NGSLyx