In Cloud 9, insurance claims can be created manually, or you can select 'initial' and 'continuation' on the Insurance Tab within the contract to have the insurance claims appear in the insurance claim queue. This comprehensive article provides an overview of the insurance claim form, detailing the information contained in each box and the sources from which it is automatically generated within Cloud 9 Software or whether it needs to be manually entered by editing the claim. Additionally, there may be a section titled 'Notes' for some boxes that outlines specific comments regarding that specific section of the claim form.
Header Information
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Box 1: Type of Transaction
-Generated from: Based on the claim being marked a predetermination or not in box 1.
-Notes: -
Box 2: Pre-Determination/Pre-authorization Number
-Generated from: Manually entered.
-Notes: Number sent to office for a pre-authorization from the insurance company.
Insurance Company Plan Info -
Box 3: Company/Plan name address:
-Generated from: Pulls from Primary Insurance Billing Center in patient record.
Other Coverage: Boxes 4-11 will only be filled out if the patient has Secondary Insurance, they will usually be left blank.
**Note: If these boxes are blank on the Insurance Claim from the contract, simply click Rebuild and the boxes will pull the information. -
Box 4: Dental or Medical
-Generated from: Dental selected from Secondary.
-Notes: Automatically selects Dental if Secondary Insurance exists in patient record. -
Box 5: Name of Policyholder
-Generated From: Name selected from Subscriber in Insurance tab.
-Notes: This is who pays for the insurance. -
Box 6: Date of Birth:
-Generated from: Date of Birth of Policyholder for Secondary Insurance/Other Coverage. -
Box 7: Gender
-Generated from: Gender of Policyholder for Secondary Insurance/Other Coverage. -
Box 8: Policy/Subscriber ID
-Generated from: Policy ID in insurance tab for Secondary Insurance/Other Coverage.
-Notes: Either an ID # assigned by insurance or the policy holder's SSN. -
Box 9: Plan/Group Number:
-Generated from: Pulls from Group # in Patient Insurance tab for Secondary Insurance/Other Coverage. -
Box 10: Patients Relationship to Box #5:
-Generated from: Pulls the Relationship type from the relationship tab of Subscriber of Secondary Insurance/Other Coverage. -
Box 11: Other Insurance Company
-Generated from: Name of Insurance company from the Edit > Patient > Insurance tab for Secondary Insurance/Other Coverage.
Boxes 12-17 apply to Primary Insurance Policyholder and will always be filled out on a claim. -
Box 12: Policyholder Name & Address
-Generated from: Policyholder name and address information, top ranked address item in the relationships tab. -
Box 13: Policyholder Date of Birth
-Generated from: Date of Birth of Policyholder for Primary Insurance. -
Box 14: Policyholder Gender
-Generated from: Gender from relationship tab of Policyholder for Primary Insurance. -
Box 15: Policy/Subscriber ID
-Generated from: Policy ID in insurance tab for Primary Insurance.
-Notes: Either an ID # assigned by insurance or the policyholder's SSN. -
Box 16: Plan/Group Number:
-Generated from: Pulls from Group # in Patient Insurance tab for Primary Insurance. -
Box 17: Employer Name
-Generated from: Name of Employer in Edit > Patient > Insurance Tab in Insurance Company setup if applicable.
Patient Information -
Box 18: Relationship to Policyholder
-Generated from: Pulls from relationship type with policyholder relationship.
-Notes: Spouse will set to spouse, family member will set to dependent, other will set to other, self will set to self, any other relationship type will set to dependent. -
Box 19: Reserved for future use
-Generated From: This box is reserved for future use and will be blank. -
Box 20: Name and Address
-Generated From: Pulls formal name and highest ranked address information for patient. -
Box 21: Date of Birth
-Generated from: Pulls patient's date of birth entered in the chart. -
Box 22: Gender
-Generated from: Pulls patients gender from chart. -
Box 23: Patient ID/Account #
-Generated from: Pulls the patient ID# assigned by Dental Practice.
Record of Services Provided -
Box 24: Procedure Date
-Generated from: If claim was created from contract, this will be the contract start date. If the claim was entered manually staff would enter the date. -
Box 25: Area of Oral Cavity
-Generated from: Manually entered. -
Box 26: Tooth System
-Generated from: Manually entered. -
Box 27: Tooth Numbers or Letters
-Generated from: Manually entered -
Box 28: Tooth Surface
-Generated from: Manually entered -
Box 29: Procedure Code
-Generated from: CDT Procedure Code -
Box 29a: Diagnosis Pointer
-Generated from: Manually entered -
Box 29b: Qty
-Generated from: Manually entered -
Box 30: Description
-Generated from: Pulls from the description of the transaction type in Edit > Setup > Transaction Types. -
Box 31: Fee
-Generated from: Fee on transaction type in Edit > Setup > Transaction Types if it is a manually created claim. It it is from a contract it generates from the amount of treatment on the contract. -
Box 31a: Other Fees
-Generated from: Manually entered. -
Box 32: Total Fee
-Generated from: Total of all the fees on claim form. -
Box 33: Missing Teeth Information (Chart)
-Generated from: Marks known extractions from the tooth chart. -
Box 34: Diagnosis Code List Qualifier
-Generated from: Manually entered. -
Box 34a: Diagnosis Code(s)
-Generated from: Manually entered -
Box 35: Remarks
-Generated from: Automatically filled in from Responsible Party side of the contract and Edit > Patient > Tracking tab. This field is currently limited to 103 characters, (Screenshot below showing where each section pulls from contract.)
-Notes:
Authorizations -
Box 36: Patient agrees to pay
-Generated from: Automatically set to Signature on File -
Box 37: Assignment of Benefits
-Generated from: Set to SIGNATURE ON FILE if Accept Assignment is checked in Edit > Patient >Insurance tab.
-Set to PAY EMPLOYEE ONLY if Accept Assignment is unchecked in Edit > Patient >Insurance tab.
Ancillary Claim/Tx Information -
Box 38: Place of Treatment
-Generated from: Automatically set to 11 (office.) -
Box 39: Enclosures
-Generated from: Manually Entered -
Box 40: Is Tx for Ortho
-Generated from: Yes by default. -
Box 41: Date Appliance Placed
-Generated from: Pulls from Case Start Date on Edit > Patient > Tracking Tab. -
Box 42: Months of Tx
-Generated from: Pulls from Estimated Months in Status on Edit > Patient > Tracking Tab. -
Box 43: Replacement of Prosthesis
-Generated from: Manually entered. -
Box 44: Date of Prior Placement
-Generated from: Manually entered. -
Box 45: Tx resulting from (Occupational injury, auto accident, other.)
-Generated from: Manually entered. -
Box 46: Date of Accident
-Generated from: Manually entered. -
Box 47: Auto Accident State
-Generated from: Manually entered.
Billing Dentist or Entity -
Box 48: Name and Address
-Generated from: This entire section is based on selections made in Edit > Practice Information > Insurance settings. Either practice information or location information can be pulled to fill these sections. -
Box 49: NPI
-Generated from: Provider Number in either Edit > Practice Information > Insurance or Edit > Setup > Location >Insurance settings. -
Box 50: License Number
-Generated from: License Number in either Edit > Practice Information > Insurance or Edit > Setup > Location >Insurance settings. (Depends on how it is set up.)
-Notes: For Dental Xchange only, the license number field that pulls into Billing Dentist/Entity section should be the Dental Xchange Account Number - NOT the provider license number. -
Box 51: SSN or TIN
-Generated from: SSN or TIN in either Edit > Practice Information > Insurance or Edit > Setup > Location >Insurance settings. -
Box 52: Phone Number
-Generated from: Data pulls from "Work" number listed in Contact info for Edit > Setup > Employees if the treating dentist claims are pulled from location level settings.
Treating Dentist and Location
**Note: Treatment Provider override located in Edit > Setup > Employees changes who is on the treatment and on the claim. House doctor located in Edit > Setup > Location > Other tab changes who is on the ledger. -
Boxes 53-58: Dr. Certification Signature, NPI, License Number, Address, Phone Number, Additional Provider ID
-Generated from: These items are all set by the options found under the Edit > Practice Information > Insurance tab. If the first option titled "Use Practice Information as Billing Entity (Claims)" is checked, it will use the Practice Information settings for the insurance as the Billing Entity, (NPI, License, Address, etc.) If it is not checked it will default to what is set under Edit > Setup > Location > Insurance tab for that patient's location. If the bottom four boxes are checked, (as shown in below screenshot), for the Treating location it will use those items under the location settings instead of what is under Practice Information.
Note that the treating entity information does pull from the Edit > Setup > Employee > Insurance tab setup.
*Note: Data pulls from a "Work" number listed in the contact info for the Treating Dentist if claims are set for location level settings. -
Box 56a: Provider Specialty Code
-Generated from: This code denotes which, if any, specialization the Dr. has. This field is pulled from the Specialty drop down in the Edit > Setup > Employee properties. (Example Screenshot below.)
-Notes: See the below chart for the specializations and their corresponding codes.
As always, if you have any further questions please do not hesitate to reach out to Cloud 9 Support by emailing us at cloud9support@planetdds.com, or chatting us online using the chat bubble on the lower right at https://cloud9support.planetdds.com/hc/en-us, or giving us a call during our business hours of 8:00 AM EST to 8:00 PM EST at the 1.800.394.6050 option 2.