A claim went out on 4 September. It is 20 October and nothing has come back. Nobody noticed because the claim is one of 140 outstanding and no one owns the list. That is the job, in one example.
What does the insurance coordinator own?
| Area | Duty | Where it shows in the software |
|---|---|---|
| Eligibility | Verify coverage, remaining maximum and deductible for every insured patient two days before the visit | Insurance plan record on the family or patient file |
| Claims | Send every claim the day of service, with attachments where the plan needs them | Claims list, status Sent |
| Pre-authorisations | Send for crowns, perio, ortho and anything over the plan’s threshold; chase the ones out more than 14 days | Pre-auth or predetermination list |
| EOB posting | Post the insurance payment to the right claim, with the contractual adjustment matching the EOB, same day | Ledger: payment plus adjustment |
| Denials | Correct and resubmit within a week; appeal where the clinical note supports it | Claims with status Denied or Rejected |
| Aging | Work every claim unpaid at 30 days; call the payer at 45 | Insurance aging report |
| Patient estimates | Give the treatment coordinator the patient share before the plan is presented | Treatment plan estimate |
What does the daily list look like?
Morning
- Eligibility for tomorrow’s and the next day’s insured patients. Note remaining maximum and deductible on the appointment.
- Claims rejected overnight by the clearinghouse. Fix and resend before 10:00.
Midday
- Post yesterday’s EOBs and EFTs. Every payment gets its contractual adjustment posted at the same time, by the same person, with the EOB reference in the note.
- Send claims for the morning’s completed procedures.
Afternoon
- Insurance aging: claims over 30 days, oldest first, 45 minutes.
- Pre-auths outstanding more than 14 days.
- Hand the treatment coordinator tomorrow’s estimates.
End of day
- Send the afternoon’s claims. Zero claims left in Created status.
- Log calls to payers with the reference number.
Which three numbers should the coordinator track?
- Claims over 30 days, count and dollars. A worked example: 140 claims outstanding, $61,000. 38 of them are over 30 days, $19,500. That $19,500 is the number to drive down week by week; the other $41,500 is just claims in transit.
- Days to payment. Date paid minus date sent, averaged over the month. 18 days is a plan that pays. 40 days is a plan with a problem or a claim with a missing attachment.
- Denial rate. Denied claims divided by claims sent. 12 denied out of 410 sent is 2.9%. Sort the 12 by reason: missing attachment, wrong code, frequency limit, eligibility. The reasons tell you what to fix at the front end.
Which reports feed the job?
- Open Dental. Reports, Outstanding Insurance Claims (filter by days outstanding); the Claims list on the account; Insurance aging under Reports. Remaining benefits are on the family module’s insurance plan with the benefit year set.
- Dentrix. Office Manager, Reports, Ledger, Insurance Aging Report; the Insurance Claims to Process window; Insurance Maximums and Deductibles.
- Eaglesoft. Reports, Insurance Aging; the claim status in the account; Money Finder for remaining benefits. Claims and insurance payments are rows in
transactions_header(type P for insurance payments).
Which errors cost the most?
- Posting an insurance payment without its adjustment. The balance moves to the patient, a statement goes out, and the patient calls. Worse, the practice’s net production looks higher than it is.
- Posting the adjustment without checking the EOB. A PPO write-off entered from memory instead of from the EOB. The write-off report on the protect side is how an owner sees this.
- Eligibility from last year’s card. The patient changed jobs; the estimate was wrong; the second appointment is cancelled.
- Claims sent without the attachment the plan needs. Perio charting, X-rays, narrative. Each one is 30 extra days.
- Nobody owns the aging list. The 4 September claim above.
What Calibic adds
The insurance, claims and AR view is LIVE. Calibic reads claims, insurance payments, adjustments and plan benefits from Open Dental, Dentrix and Eaglesoft (read-only, it never changes a record) and shows outstanding claims by age, AR by bucket, and the patients with remaining benefits, with each figure opening to its source rows. Protect (LIVE) separately flags adjustment patterns that do not fit the account. Calibic does not submit claims or contact payers. The end of year benefits page is the seasonal part of this job.
Next step: the insurance, claims and AR product page.