DENTAL INSURANCE CLAIM SUBMISSION WORKFLOW: MAXIMIZE REIMBURSEMENT & MINIMIZE ERRORS

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

[ ] Retrieve Patient Insurance Details: Get primary insurance policy and contact information from the Patient Data Model.
[ ] Retrieve Treatment Plan Details: Get necessary services and associated codes (CDT codes) from the Treatment Plan Model.
[ ] Review Claim Eligibility Task: Assign a task to the Billing Specialist to verify patient coverage and deductible status.
[ ] Calculate Estimated Patient Responsibility: Execute formula: (Total Cost - Insurance Coverage) to determine patient portion.
[ ] Update Claim Submission Status: Update the Claim Record Model with the current submission status (e.g., 'Submitted', 'Denied', 'Paid').
[ ] Generate Initial Claim Draft: Create a new draft entry in the Insurance Claim Model using gathered service and patient data.
[ ] Retrieve Provider Credentials: Fetch necessary provider NPI and Tax IDs for the claim submission.
[ ] Pre-Submission Review Task: Assign task to the Office Manager to review required supporting documents.
[ ] Send Preliminary Claim Status Email to Patient: Notify the patient with an estimated out-of-pocket cost before submission.
[ ] Verify Copay/Deductible Thresholds: Check current payer guidelines against service codes to anticipate potential claim rejections.
[ ] Attach Supporting Documentation: Link necessary records (X-rays, consent forms) to the claim file.
[ ] Calculate Total Claim Amount: Sum all associated service unit charges from the treatment plan.
[ ] Final Billing Review Task: Require final sign-off from the billing supervisor before sending to payer.
[ ] Generate Claim Submission Report: Create a structured report detailing all billed services and associated codes for audit purposes.
[ ] Send Reminder to Complete Missing Forms: Send an SMS reminder to the patient if required forms are missing for accurate billing.
[ ] Log Payer Correspondence: Create a log entry for any communication received from the insurance company (EOB/ERA).
[ ] Retrieve Encounter Dates: Gather the date of service to ensure the claim falls within the current benefit period.

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