Step 6: Chapter 7 - Claim Entry for Prime Smile Dentistry (ADA-J430 Form)

Training Video

After completing the Patient Registration section, the next step in the patient visit process is Claim Entry.  Post all fee tickets contained in the Claim Entry section of the workbook .
   Following are the page numbers for each Claim Entry section:

                                    Prime Smile Dentistry, pg 71

Select Claim to enter each superbill (claim). 

Type of Claim, New or Existing?

It is important to know the difference between creating a new claim versus updating an existing claim.

Search Claim by Name: Place your cursor in this field and type in either part of or the full patient first or last name. The results will
filter all patients with these specific characters found in the database and display them alphabetically in an organized table. Always
search here first to determine whether patient and claim are already in the system to prevent duplicate claim entry. All saved claims
will display here.

Add Claim: Click this button to begin adding a new claim.

Review the Tabs
There are eight tabs across the top of each claim.  The first three tabs contain the necessary information to complete your ADA J430 form.

The eight tabs and descriptions are:

 1.     Claim: Contains treating and billing dentist; insurance information; and claim preauthorization #.

 2.     ChargesEnter all CDT codes, diagnosis codes, and all relevant charges and payments.

 3.     Additional InfoContains missing teeth, claim dates, and accident information, if provided.

 4.     Insurance: View the patient’s current payer ID numbers.

 5.     Activity: Shows transactions for this claim.

 6.     Notes: Not applicable.

 7.     Alerts: Not applicable.

 8.    Documents: Not applicable.


How Many Claims Per Patient?
It is important to verify the number of claims your assignment requires.  This information is located in the third column of the Patient Listing report in the workbook .    

        Following are the page numbers for the Patient Listing Report:

                                Prime Smile Dentistry, pg 4

Add a New Claim to a Patient 

Before assuming you need to Add a claim, it is important to verify the number of claims your assignment requires (see the previous information). 

To add a claim into the system, click the Add Claim button. Next, click the Blank Claim or the Add for Patient Name button.

1. If you click the Blank Claim option, you must immediately click the Select Patient icon and search for the desired patient. 

2. If you click the Add for Patient Name option, the active patient that is displayed at the bottom left of the software will populate in

1 Claim tab.

                                                                                                   Active Patient

Find an Existing Claim
You can retrieve an existing claim to fix errors.  To find a claim, click the Find button or Find for Active Patient button.

Place your cursor in the Search field and type in either part of or the full patient’s first or last name. The results will filter all patients with these specific characters found in the database and display them alphabetically in an organized table. Always search here first to determine whether the patient and claim are already in the system to prevent duplicate claim entry. All saved claims will display here. Click the Search button.

1 Claim Tab

Once a patient is selected, most of the previously entered patient information will default here. Double check the information that does
default, and complete the remaining fields.
* Should be defaulted from the initial Patient 
** Needs to be completed with claim information provided in the workbook .

1.    Claim #: Auto-fills.

2.     Claim CompleteAll claims will be checked as “Claim is complete,” unless when you click to Save the claim, an information
       screen informs you that this claim is incomplete and asks if you would like to continue to save as “incomplete.” If you choose to           save your claim as incomplete, you must remember to get the correct information and enter it in the incomplete/incorrect claim,        and then check the box to make the claim complete before saving. A claim that is not complete results in a score of 0 (zero).

3.     Type of Transaction: Defaults to proper setting as Statement of Actual Services..

4.     **Select Patient: When adding a new claim, you will need to search for your patient here. Once selected, the defaults from the        patient registration process will populate.

5.     *Select Treating Dentist: A provider will default if already entered in Patient , 4 Claim Defaults tab. Listed at the top of
       the encounter form is the provider who is treating the patient.

6.     *Select Billing Dentist: This should default from the treating dentist field.

7.     *Select Primary/Secondary InsuranceIf the payer information does not default here, then return to Patient and
        complete the required payer information in the 3 Insurance tab. Before saving any updated information, be sure to
        remember and check the box at the top of the screen to update all saved claims, and then click Save. Screens of this field
        can be referred to on pages 32 and 40.

8.     Form Version J430DThe specific claim type.  

9.     **Predetermination / Preauthorization #: If an authorization number is given on the fee ticket, enter it here.

2 Charges Tab

Begin this screen by setting the number of rows based on the number of charges on the fee ticket. Then place your cursor in the
Service Date field to start entering the claim information. Press Tab on the keyboard to continue to the next field. 

All the following fields are described and need to be completed:

  1.     ICD: Enter up to four diagnoses beginning in field A.

  2.     Set Rows: Count how many charges you will post and enter the number here.

  3.     Procedure Date: Enter the date of service.

  4.     POS: Defaults to the proper office code.

  5.     Area of Oral Cavity: Enter if information is provided, but not required on the ADA J430 claim.

  6.     Tooth System: Defaults to the proper system code JP used for this exercise.

  7.     Tooth Numbers or Letters: Type or search and select, the tooth number or letter when provided on the superbill. 

  8.     Tooth Surface: Type the surface(s) when provided on the superbill. 

  9.     CDT: Type or search and select, the procedure code as listed on the superbill.

10.     Unit Price: Enter the price of the procedure.

11.     Units: Enter the number of times this procedure is performed.   

12.     Description: The description of the procedure will default.

13.    Total Charges: The price of the procedure will calculate.

14.    Status: Select the option based on whether the insurance payer is electronic or paper.


3 Additional Info Tab

 1.     Missing Teeth Information (Box 33): Click the number of tooth (teeth) missing when provided on the health history form.

 2.     Remarks(Box 35): Enter any remarks pertinent for the claim to be processed.

 3.     Print Signature on File in Box 36 and 37: Defaults yes to print signature.

 4.     Enclosures (Box 39): Indicate whether the patient has enclosures.   

 5.     Orthodontic claim (Box 40): Indicate whether charges are related to orthodontic care.

 6.     Appliance Placed (Box 41): Enter the date an appliance is placed, if any.

 7.    Months of Treatment Remaining (Box 42): Indicate how many months remain for patient treatment.

 8.     Replacement of Prosthesis (Box 43): Indicate whether a procedure was a replacement of prosthesis.

 9.     Date Prior Placement (Box 44): Provide the date of a prior placement.   

 10.   Treatment Resulting from (Box 45): Click the proper box to indicate whether an injury or accident.

 11.   Date of Accident (Box 46): Enter the date of accident (Box 46) if box 45 is checked.

 12.   Auto Accident State (Box 47): Enter the states abbreviation in which the accident occurred.


 4 Insurance Tab

This screen provides the opportunity to view and edit any insurance information.

5 Activity Tab

The Activity report lists the activities for all charges on this claim only. This is a good way to confirm postings (both charges and EOBs) and aging.

Click the List Activity    button . The report will display for you to view or Print this activity report.

Save Your Work

After completing the 1 Claim tab, 2 Charges tab, and 3 Additional Info tab, it is time to save the claim.

If you don’t want to Save your work, click the Close button.

Practice Revenue Cycle Activities: Claim Management

The practice revenue cycle activities are a combination of discussion questions and activities using ClaimGear and its workbook .

It is important to complete the claim entry task correctly and efficiently. After you have generated the claims as required, complete the
following tasks to further enhance your revenue cycle experience as it relates to your current ClaimGear  assignment.

        1.     Did you enjoy experiencing the dental form?
        2.     Create an alert for a couple of patients. Is this function useful in this type of office?
        3.     How many teeth cleanings were performed total? (Generate the Management, Procedure Done report.)
                a.     How much did you bill the insurance company for this procedure?
                b.     How much have you received from the insurance on payment for this procedure?
        4.     The claim review process and claim submission process are simulated through our electronic claims scoring. The goal of
                the biller is to submit electronic claims correctly the first time without any rejections.
                a.     How many claims did you receive 100% on when you scored for the first time?
                b.     How can you improve your claim entry? Suggestions for improvement include becoming more efficient, taking more
                        time to do the job correctly, and understanding the process better or understanding the software fields better.