DENTAL INSURANCE CLAIM PROCESSING WORKFLOW: STREAMLINE BILLING & MAXIMIZE REVENUE

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

[ ] Retrieve Patient Profile Data: Fetch existing patient demographic and insurance information.
[ ] Retrieve Procedure Codes (CDT/ADA): Get master list of billable dental procedure codes and associated fees.
[ ] Retrieve Insurance Policy Details: Fetch patient's specific insurance plan rules and coverage details.
[ ] Assign Claim Review Task to Biller: Automatically assign the generated claim packet to the designated billing specialist.
[ ] Generate Initial Claim Draft: Create the initial claim record using captured services and patient data.
[ ] Calculate Total Service Cost: Sum all billed service units to get the total charges before adjustments.
[ ] Determine Deductible Responsibility: Calculate patient portion based on plan rules and service codes.
[ ] Calculate Copay Amount: Apply the determined copayment amount for the specific insurance plan.
[ ] Update Claim with Adjusted Amounts: Write the calculated amounts (Total Cost, Deductible, Copay) back into the claim model.
[ ] Verification Check: Missing Information?: Create a task for the biller to verify missing required fields on the claim.
[ ] Send Pre-Submission Check Email to Dentist: Notify the treating dentist to review the final claim details before submission.
[ ] Generate Claim Submission Summary Report: Compile a summary report including services, amounts, and expected payment.
[ ] Mark Claim Status as Ready for Submission: Change the claim status in the system to indicate it's ready for the carrier.
[ ] Follow-Up Required: Submit to Payer Portal: Create a task to physically submit the claim through the designated dental insurance portal.
[ ] Check Previous Claim Status: Retrieve the status of the last submitted claim for auditing purposes.
[ ] Send Explanation of Benefits (EOB) Notification: Email the patient/office manager with the EOB once received from the insurance company.
[ ] Manage Overpayment Recovery Task: Create a follow-up task if an overpayment is identified on a claim.
[ ] Record Payment Received: Update the claim entry with the final payment amount and posting date.

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