DENTAL BILLING CHECKLIST: CLAIMS & PAYMENT VERIFICATION

Created by ChecklistGuro (https://checklistguro.com)

--- PATIENT INFORMATION VERIFICATION ---
[ ] Patient First Name
[ ] Patient Last Name
[ ] Patient Date of Birth (Year)
[ ] Patient Date of Birth
[ ] Patient Address (Street)
[ ] Patient City
[ ] Patient State (Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, Wyoming)
[ ] Patient Zip Code
[ ] Primary Insurance (Yes, No)

--- PROCEDURE CODING & DOCUMENTATION ---
[ ] Procedure Code (CPT/HCPCS)
[ ] Procedure Description
[ ] Narrative Notes (if applicable)
[ ] Anesthesia Type (if applicable) (Local Anesthesia, General Anesthesia, Nitrous Oxide, None)
[ ] Units/Quantity of Service
[ ] Date of Procedure
[ ] Diagnosis Codes (ICD-10)

--- CLAIM SUBMISSION ---
[ ] Submission Method (Electronic Claim (Clearinghouse), Manual Paper Claim)
[ ] Claim Number (if applicable)
[ ] Payer ID
[ ] Date of Service
[ ] Notes/Comments (e.g., authorization number, specific instructions)
[ ] Claim Form Version

--- PAYER ELIGIBILITY & AUTHORIZATION ---
[ ] Insurance Verification Method (Online Portal, Phone Call, Fax, Email)
[ ] Authorization Number
[ ] Verification Date
[ ] Pre-Authorization Required? (Yes, No)
[ ] Authorization Expiration Date
[ ] Notes/Comments

--- CLAIM TRACKING & FOLLOW-UP ---
[ ] Claim Number
[ ] Date Claim Submitted
[ ] Date of Initial Follow-Up
[ ] Claim Status (Submitted, Received by Payer, Processed, Paid, Denied, Pending)
[ ] Payer Notes/Communication Log
[ ] Reason for Follow-Up (if applicable) (No Response, Request for Information, Payment Issue, Denial Inquiry)
[ ] Date of Next Follow-Up
[ ] Contact Person at Payer

--- PAYMENT POSTING & RECONCILIATION ---
[ ] Payment Amount Received
[ ] Date of Payment Received
[ ] Payment Method (Cash, Check, Credit Card, Insurance Payment, Other)
[ ] Claim/Invoice Number
[ ] Notes/Comments (e.g., Explanation of Benefits details)
[ ] EOB Amount
[ ] Adjustment Reason (If Applicable) (Contracted Rate, Duplicate Claim, Patient Responsibility, Other)

--- PATIENT STATEMENTS & APPEALS ---
[ ] Statement Balance
[ ] Statement Date
[ ] Patient Inquiry Summary
[ ] Resolution Status (Resolved, Pending, Escalated)
[ ] Resolution Details (if applicable)
[ ] Appeal Filed? (Yes, No)
[ ] Appeal Submission Date (if applicable)
[ ] Appeal Notes (if applicable)

--- COMPLIANCE & AUDIT ---
[ ] Last Compliance Audit Date
[ ] Number of Claims Audited
[ ] Areas Audited (Check all that apply) (Coding Accuracy, Documentation Completeness, Authorization Verification, Patient Demographics, Payment Posting, Other (Specify in Long Text))
[ ] Details of 'Other' Area Audited (if selected)
[ ] Number of Coding Errors Found
[ ] Number of Documentation Errors Found
[ ] Corrective Actions Taken (if any errors found)
[ ] Date Corrective Actions Completed
[ ] Audit Outcome (Satisfactory, Needs Improvement, Unsatisfactory)

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