For Canada users, in the Account Module, click New Claim, or double-click an existing claim to edit.

To send electronic claims (e-claims), setup the ITRANS 2.0 or Claimstream clearinghouse first.

Canadian Tab

The Canadian tab contains specific Canadian information.

Referring Provider

• CDA Number or Identifier: Canadian Dental Association identifier of the referring provider.
• Reason: The reason why the referring doctor chose to refer the work related to this claim.

Accident Date: Used to indicate that dental treatment was needed as the result of an accident. If a value is entered, the Is Accident field on the printed claim will automatically be marked.

Trans Ref Num: When a claim is sent electronically, this box is automatically filled with a unique transaction reference number composed of letters and numbers. To reverse or unsend a claim, click Reverse. This button is only enabled when the claim has already been sent earlier that same day (determined by the existence of the Trans Ref Num).

Materials Forwarded (email, correspondence, models, X-rays, images): Indicate the types of supporting documents which have been physically mailed to the insurance carrier. These boxes can be checked/unchecked independently.

Treatment Required for Ortho: Only used for Ortho claims. If checked, the ortho flag is sent.

Ortho Treatment (Predetermination Only): Only for predetermination claims, not regular claims.

• Estimated Treatment Start Date: The treatment plan date for the first appointment regarding this orthodontic treatment.
• Initial Payment: The amount the patient will pay out of pocket at the first appointment.
• Expected Payment Cycle (Months): Frequency of payments related to the orthodontic treatment. Accepted numbers are 1-4.
  • 1 - Once a month.
  • 2 - Every two months.
  • 3 - Every three months.
  • 4 - Every four months.
• Treatment Duration (Months): The number of months it will take to entirely finish the orthodontic treatment.
• Number of Payments Anticipated: Number of total expected patient payments for the orthodontic treatment.
• Anticipated Pay Amount: Total patient payment amount regarding the orthodontic treatment.

Maxillary Prosthesis

• Initial placement upper: For the upper arch only. Indicate whether the prosthetic work associated with this claim is or is not the first prosthetic, or if there is no prosthetic.
• Initial Date: If initial placement upper is set to No, then this date is required and is the date that the prosthetic was first added to the patient's mouth.
• Prosthesis Material: Describe the prosthetic material used for the initial placement. Required when initial placement upper is set to No.

Mandibular Prosthesis

• Initial placement lower: For the lower arch only. Indicate whether the prosthetic work associated with this claim is or is not the first prosthetic, or if there is no prosthetic.
• Initial Date: If initial placement lower is set to No, then this date is required and is the date that the prosthetic was first added to the patient's mouth.
• Prosthesis Material: Describes the prosthetic material used for the initial placement. Required when initial placement lower is set to No.

Extracted Teeth: List of the patient's extracted teeth. For display only. Change the extraction status of teeth in the Chart Module.

Missing Teeth: List of the patient's missing teeth. For display only. Change the extraction status of teeth in the Chart module.

Procedures

Up to seven procedures can be included on a claim, per CDA limitations. If sending more than seven procedures, create multiple claims.

Claim Responses and Payments

When a claim is sent electronically, a response is generally received immediately. In some cases, responses may take a few moments to be returned. There are are three possible claim responses:

• Rejection
  • Verify the patient, subscriber, and plan information, then try again. If the claim is rejected again, contact the carrier for further guidance.
• Explanation of Benefits (EOB)
  • Claim EOB: Insurance paid amounts will automatically be entered on the Edit Claim window, though users will still need to finalize the payment. See Finalize Insurance Payment.
  • Preauthorization EOB: Amounts will automatically be entered as estimates. Automatic insurance paid amounts can be turned on/off in Claimstream Setup or ITRANS Setup.
  • Patient balances will update according to the EOB when the clearinghouse option is set to either Download EOBs, Do Not Auto Receive or Download EOBs and Auto Receive.
• Claim acknowledgment report. This is not the same as an EOB. The carrier may send their response by mail or electronically as a mailbox item (Outstanding Transaction). See, Send Canadian Claims and Retrieve Reports.

A response may come back in French for a subscriber.

1. If the carrier has the subscriber's preferred language set to French on their end, then we honor the carrier's information and will display the response in French.
2. If the subscribers's preferred language is set to fr in the Edit Patient Information window, then we display the response in French, even if the preferred language is English for the carrier.
   
   Note: In order to display responses in French, a custom language of fr must be added in Language Definitions. Using French will not work.
3. The disposition and notes on a response come directly from the carrier. Sometimes this information displays in English, sometimes French, and sometimes both. There are no settings in Royal dental Software to change this.

Also see Canada Insurance Plans.

Substitutions

If a carrier substitutes a code, the substitution code is added as a new row in the Edit Claim window. This allows the user to view the submitted code as well as the substituted code.

E-Claims and Sunlife

When sending e-claims, both the treating dentist and billing dentist are submitted. If using the Canadian insurance carrier Sunlife, the treating dentist will receive the payment instead of the billing dentist. This is a decision made by Sunlife.

Reversals

Claims can sometimes be reversed on the day they are sent. Claims can only be reversed on the same day, by carriers that support claim reversal, and when a Transaction Reference Number is generated (see Canadian Tab above).

If a claim needs to be reversed on a date later than the date it was originally adjudicated, the carrier does not support claim reversals, or a transaction reference number was not generated, the claim must be reversed manually by contacting the carrier.

Automatic Printing

ITRANS and Claimstream require automatically printing patient copies of certain forms in particular circumstances. Dentist copies are never automatically printed. A single patient copy of a response from ITRANS or Claimstream automatically prints immediately in the following situations:

• After a claim is sent, if the response is not a rejection notice.
• After a claim reversal request.
• After a request for outstanding transactions (each item will print separately).
• After a payment reconciliation request.

A claim form prints automatically in these scenarios:

• When the carrier sends a response that manual printing is need (etrans AckCode M).
• When the secondary carrier does not support COB claim transactions.

Responses should be printed or saved immediately after being received. If actions are taken on the claim after receiving the response (such as deleting the claim, changing patient information, updating carrier information, etc), the preview may contain inaccurate information.

Some offices find the extra printing less useful than others. There are a few options if you do not want to automatically print copies:

1. On each computer where claims are typically processed, set the default claim printer to a PDF printer.
2. In File, Print, Claims, select the Prompt option. Then you will be prompted before printing begins and have the option to cancel the print job. See Printer Setup.

Secondary Claims

If a patient has primary and secondary insurance:

• When the primary claim is sent electronically and receives an EOB, a secondary claim is automatically created. Otherwise, you will need to manually create a secondary claim. Click the dropdown next to New Claim and click Secondary.
• The secondary claim response will display after the primary claim's EOB has been closed.

There are two electronic message formats for Canadian claims, version 02 and version 04.

• Secondary electronic claims are not possible for carriers that still use version 02 message format.
• Secondary claims will be sent electronically and automatically if the primary claim was sent to a version 04 carrier, an EOB has been received for the primary claim, and the secondary carrier accepts secondary (COB) claims.
• In any other case, secondary claims must be sent by physical mail.

It is best practice to first create the primary claim and send it or print it before worrying about the secondary claim because sometimes the secondary claim will be created and possibly sent electronically and automatically.

Preauthorizations

Primary preauthorizations are available for carriers that accept them. On the claim form, there is no official box to indicate Preauthorization. The carrier identifies a claim as a preauthorization when there are no procedure dates. To show the word Preauthorization on a printed preauthorization, manually add the field ShowPreauthorizationIfPreauth to claim forms.

Royal dental Software does not support the electronic sending of secondary preauthorizations (COB predeterminations).

If a patient has dual insurances from the same carrier (i.e. blue-on-blue), the carrier may coordinate secondary coverage estimates automatically and send two responses to Royal dental Software. These will display one after the other.

Electronic Attachments

Royal dental Software does not support electronic attachments or narratives (claim notes) at this time.

Troubleshooting

If insurance requires student school and status, enter it on the Edit Patient Information under Name of School and Eligibility Excep. Code.