Pre-Authorization (Pre-Auth) Claims and Procedure Posting Workflows FAQ

Introduction:
When a Pre-Authorization claim is sent for a procedure before it was posted to the Ledger and a regular claim was sent, you may find that the claim was closed out upon creation. Below are a few common questions you may want to consider when attempting to collect from insurance. If your claims are automatically closing, you may need to make adjustments to the way certain procedures are billed to avoid future instances of this issue.

• Question 1: I had a claim for a pre-authorized procedure close automatically. Why might this have happened?

  • Answer:

  • If a procedure is on a Pre-Auth is marked as uncovered Denticon will close the claim without submitting it as it understand that there will be no payment remitted for that procedure.

• Question 2: What can I do to look for procedures in the Treatment Plan screen where this case might apply?

  • Answer:

  • In the Treatment Plan, Expand all treatments and look for entries in the PS column. 

  • Example:

    1. Navigate to Transactions and select Treatment Plan.
    2. Look at the PS Column in the header of the Treatment Plan.
    3. If there is a PS populated for the procedure you created the claim for, hover your cursor over the PS text on the line of the procedure.
    4. If the Pre-Authorization status is declined, any claims with the procedure attached will likely be closed as soon as it is created as the procedure is anticipating no payment from the Insurance company.
       • In cases like this, the claim is closed as soon as it is opened to move the owed balance to the Est Pat column of the patient's Ledger.
       • Visual Example

• Question 3: Are there multiple "Primary [insurance] Claims" next to each other in the Ledger?

  • Answer:

  • If there are multiple Primary Claims that neighbor each other in the Ledger, this may also signal that a Pre-Authorization was involved in the claim closing.

• Question 4: If there are multiple closed claims, do they share the same denials and insurance plans?

  • Answer:

  • In cases where a Pre-Authorization causes an 'issue' with claim submission, if the same insurance plan is used between multiple patients impacted, this may be a sign that the denials of claims are related. 

  • This may mean that you need to create an exception of coverage for the specific code being denied on the insurance plan. 

    • See this article for more information: An insurance carrier informed us that a specific procedure is covered 1 year after the last Date of Service. How can we indicate this option to reflect in the Insurance Plan – Coverage and Limitations?

• Question 5: In cases where there is more than one insurance on the patient's account, what should I expect once the Primary Pre-Authorization Claim is closed, what should I expect?

  • Answer:

  • Once the Primary Pre-Authorization Claim is closed, the treatment plan will push the Primary Insurance's estimate to the Secondary Insurance and the Secondary Pre-Authorization Claim will be ready to be created and sent. 

• Additional information:

  • How to Create a Pre-Authorization

  • An insurance carrier has returned its estimated coverage for a pre-authorization (pre-auth) claim. How do we update the estimated coverage amount in Denticon?  Are we able to update the pre-authorization (pre-auth)?

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