Manage your insurance billing in OptiMantra

Once you’ve completed the steps in “Getting started with insurance billing,” you’re ready to go live with insurance billing for your practice! 

TABLE OF CONTENTS

• Collect Patient Insurance Information
• Check Insurance Eligibility for your Patients
• Submitting and Managing Claims
• Applying Co-Pays to Superbills
  • Creating and Submitting Your Claims:
• Reconciling Insurance Payments
• Analytics
• Live Training and Support
  • Visit our Glossary for explanations of terms mentioned in this article. 
• Tips for Successful Insurance Billing

Collect Patient Insurance Information

To add insurance information to a patient’s profile, navigate to the Patients screen and open the Actions menu (represented by three stacked lines) for the patient you want to update. 

From the Actions menu, select Profile under Admin, then click the Insurance tab. 

• Note: If the patient provided their insurance information during scheduling, it will automatically appear in their Profile.

In the Insurance field:

• Type the first 2–3 letters of the insurance company’s name, then select the correct company from your Contact List. This will automatically fill in the insurance details for that patient.

• Click the blue box Copy From Demographics to copy over the same patient address that’s listed in the Demographic tab.

  • If the patient has a different address on file with the insurance company, you can update it here.

• Enter the patient’s policy ID in the Insured ID Number field (located on the insurance card).

• Enter the patient’s group number in the Insured Group Name/No field (located on the insurance card). 

  • Note: Medicare and Federal plans typically don’t include a group number. Leave this field blank if none is provided.

• Enter “Self” in the Relationship to Insured field unless the patient is the spouse, partner, or a dependent under 26 years old of the insured individual.  

  • If you select “Self,” leave the Insured Name, Date of Birth, and Gender fields blank. 

  • If you select any other relationship, be sure to fill in these fields with the insured person’s information.

• If you know the patient’s copay, enter it in the Co Payment$ field to facilitate easy collection at the time of service.

• Co-insurance is the portion of the allowed amount (the amount the insurance company agrees to pay for a service) that the patient is responsible for paying. It is not a percentage of your original charged fee.

  • If the co-insurance amount is consistently the same, you can either note the percentage in the Co-Insurance % field or convert it to a fixed copay amount.

• If the patient has secondary insurance, enter the details in the Secondary Insurance tab within the Patient Profile, following the same steps used above for Primary Insurance.

Sample view of the Insurance tab in a Patient Profile:

Recommendations

To ensure accurate billing and claim submission, it is important to collect and verify complete insurance information from each patient at the time of intake. Retaining copies of identification and insurance cards helps prevent errors and delays in the claims processing phase.

• Make sure to record the patient’s information exactly as it appears on their insurance card, including:

  • Full name (as written on the insurance card)

  • Date of birth

  • Insurance policy number

  • Group number (if applicable)

  • Insurance company name

• Confirm that the details are accurate and up to date before submitting claims. Incorrect or missing information can lead to denials or delays in payment.

• Keep a copy of the patient’s driver’s license (or other photo ID) and a copy of their insurance card for reference. Patients can also upload their information directly from within their patient portal!

Check Insurance Eligibility for your Patients

Before getting started, note that to verify a patient’s eligibility, your setup needs to be completed:

• Patient insurance information needs to be added from your Contact List in the Insurance tab of their Patient Profile. Refer to the Get started with insurance billing article for step-by-step instructions for setting up your Contact List. 

  • For the eligibility check to function properly, the information on the patient’s insurance tab must be accurate.

• Billing provider information needs to be completed under Settings.

  • OptiMantra’s eligibility tool utilizes the NPI from the default billing provider specified in the Provider Settings Profile. This is located under Settings > Business > Provider Settings. 

  • Ensure that the NPI associated with your credentialing is entered correctly so you receive accurate eligibility information.

To perform an eligibility check, follow the below steps:

• From the patients list, click the Actions menu (three horizontal stacked lines) for the patient.

• Under the Admin section, click Profile. 

• From the patient's profile, click the Eligibility Check tab. 

• Select whether the insurance is primary or secondary.

• Choose the provider and coverage type.

• Select the payer if it’s not already listed. 

• Then, click the blue Check Eligibility button.

• You can bypass the Payer Portal Login and Portal Pass fields. They are only used in special cases and will be explained if needed.

 → When an eligibility check is successful, you will see a button titled "View Response" next to the "Check Eligibility" button. Click the "View Response" button view the patient's eligibility. 

Note: The program automatically saves the eligibility response in the patient’s documents. 

If you’ve completed all the steps above and still experience issues with eligibility checks, please submit a support ticket.

Submitting and Managing Claims

Once your systems are set up, you’re ready to submit claims to patients’ insurance for visits and process payments received from both insurance companies and patients.

Applying Co-Pays to Superbills

At the time of treatment, create a Superbill to record only the collection of the copay, co-insurance, or deductible.

• Do not add any insurance services to your initial/original Superbill, as they will be automatically posted on a separate Superbill when the insurance payment is received.

• You can check out the patient using Checkout at the bottom of the Appointment box by selecting Charge Copay. 

• Alternatively, generate a Superbill from the Checkout screen by clicking +Superbill for that visit

• Another way to generate a Superbill is by clicking the "Save Consult & Create Superbill” button at the bottom of the chart. 

Creating and Submitting Your Claims:

To prepare a claim, be sure the necessary information is recorded in the patient’s chart note during the provider visit. In the Assessment section, the provider (or biller) should enter:

• Services provided – CPT codes will auto-populate if they’ve been added to the service.

• ICD diagnosis codes – use Favorites to speed up selection

• Modifiers – as applicable

• Diagnosis references – if needed

• After completing the Assessment section of the chart note, the provider can select “Save Consult & Create HCFA” at the bottom of the chart.

  • You can also generate a claim by clicking the +Claim button on the Checkout screen.

• Once you’re finished with a chart, you can lock it by clicking Lock & Sign Consult at the bottom of the chart page. 

  • Charts can be unlocked, and you can also create an addendum if needed. 

• Steps for unlocking a chart

• Steps for creating an addendum

Tracking Your Claims:

Once the claim is submitted to the clearinghouse:

You can view all your claims under Shortcuts > Administrative > Insurance Claims (HCFA). 

• You can sort and filter claims by Practitioner, Starting Date, and Ending Date (date fields refer to the date of the claim). 

• Claims submitted to the clearinghouse will display a status of ‘Submitted to clearinghouse’.

• After passing through the clearinghouse, the claim is sent to the insurance, and the claim status will update to ‘Submitted to Payer’.

• If the insurance company’s claim scrubber accepts the claim, the status will change to ‘Payer is Processing’.

• Note: You can view all outstanding visits on your Checkout screen. 

  • Click All Claims (HCFA) in the top right corner to move to the Claims Listing page – see below. 

• When viewing claims from the Checkout page, you’ll notice either a green, red, or black/gray circle in the claims column next to the dollar amount. 

  • Green: claim was submitted. 

  • Red: claim was submitted and there are errors. 

  • Black/grey: claim was not submitted.

Managing Claim Errors and Rejections:

The clearinghouse and/or insurance may identify errors with a submitted claim. Here are some tips to help you understand and address these errors:

• Navigate to the Claims Listing page: Shortcuts > Administrative > Insurance Claims (HCFA)

• Click on Status to sort claims by the status message and bring those with errors to the top of the page. 

• In the Status column, find the listed error. Then, click Details to open the full error response (see below).

  • Note: the clearinghouse errors will be listed under Clearing House File.

• To correct the errors, click Edit, located in the Edit/PDF column & make the corrections on the claim. 

• Then scroll down to the bottom of the claim page and click Save and then Submit Claim to submit your corrected claim. 

  • Note: Resubmission codes are only required when a claim has been processed by the insurance company and is being resubmitted. They are not required for corrected claims resulting from clearinghouse errors.

→ If you’d like more details on Office Ally error codes, review our KB article: Understand Office Ally error codes.

• If the Details box displays information from the insurance company (under payer file), it indicates that the claim has been processed by the insurance company. 

  • If you need to resubmit the claim, you must include a Resubmission Code to avoid a duplicate claim denial from the insurance.

    • 7 – Resubmission of a corrected claim.

    • 8 – Void/Delete (to be used when a claim was billed in error).

    • 1 – Medicare resubmission for a corrected claim.

  • In the “Original Ref. No.” field, enter either the original claim number (found in the Details box) or, if available, the Claim Control Number from the EOB or ERA.

• If the claim status shows ‘Payer is Processing’ and more than 30 days have passed since submission, contact the insurance company directly to confirm the claim was received and is still being processed.

  • If the insurance company does not have the claim on file, resubmit it without a resubmission code, as the original claim was not received.

Reconciling Insurance Payments

At the time of service, generate a Superbill solely to document the collection of copay, coinsurance, or deductible amounts. 

• As mentioned above, do not include service codes, as these will be automatically recorded on a separate Superbill upon receipt of the insurance payment. 

• Refer to the ‘Applying Co-pays to Superbills’ section for additional guidance.

As your insurance checks are received, the next step is to post payment. Payment posting is the process of recording insurance payments and adjustments to patient accounts, ensuring that balances are accurate and up-to-date.

Payment posting starts on the Claims Listing page under Shortcuts > Claims (HCFA) under the "Billing & Sales" header. 

• Then click the blue Payment Posting box to select how you want to apply write-offs. Most users select "Everything except PR (Patient Responsibility) Items on EOB/ERA", especially when working with contracted insurance rates.

  • This only needs to be completed the first time you post a payment. After that, the setting will remain in place for future payments, but it can be updated at any time if needed.

• If you have ERA set up, go to the EOB Checks tab from the Claims Listing page under Shortcuts > Admin > Insurance (HCFA).

• Click the check number, select the corresponding HCFA, and review the partially posted payment for accuracy. Manually enter any copay, deductible, or coinsurance amounts, as these fields do not auto-fill and do not affect the total.

• Ensure the ‘Create SuperBill with details from the EOB' box to record the insurance payment as the superbill will serve as the insurance payment receipt. If anything was applied to patient responsibility, you can then invoice the patient, collect payment at the next visit, charge a card on file, or send a statement.

• If the patient has secondary insurance, enter the necessary adjustments at the bottom of the screen or pull them from the ERA section in the EOB Check Listing. Then click ‘Generate Secondary Claim.’

  • Note: If a patient has secondary insurance, Medicare usually sends the claim to the secondary payer after it’s processed. They won’t do this if the patient hasn’t told Medicare about their secondary insurance.

  • If you are billing the secondary insurance by paper rather than through OptiMantra, click ‘Save’ to keep the secondary claim in the pending claims list.

  • For all other payments, click Save and Mark Done to remove the claim from the pending list and ensure accurate bookkeeping.

Manual Check Entry (if you’re not set up to receive ERAs)

An ERA (Electronic Remittance Advice) is a digital version of an explanation of benefits (EOB) that provides detailed information about how insurance claims were processed, including payments, adjustments, and denials. It helps streamline payment posting and reconciliation. Learn more about ERAs in this article.

If you're not set up for ERA/EOB entry directly in OptiMantra, you can manually enter claim information from payment details through Availity, the payer’s online portal, or mailed/faxed EOBs. The posting steps remain the same, but you will need to enter the information manually.

• To do this, click the "NA" in the pending claims list or use the Payment Posting box next to the claim in the patient’s Dashboard under Visits and Claims.

• If you have a paper check and EOB, click the Manual Check Entry blue button on the Shortcuts > Insurance (HCFA) page. After entering the check number and date, save it. Then, a patient search box will appear, allowing you to enter each patient’s name separately until the full check amount is posted.

• After you enter the payment information, the patient’s account will typically show one or two superbills with matching charge and payment amounts. If the amounts don’t match, it indicates there is still an outstanding balance.

• After entering all EOBs, ERAs, or payments for the day, go to Analytics > Insurance EOB by Date of EOB report to verify that the total payments on the report match the amounts you entered.

  • When recording insurance payments, the system defaults to the entry date. It’s best to leave this date unchanged to avoid confusion with deposit or EOB dates. When entering payments manually, always include the check number for easy reference later.

• When running the Analytics Deposit report, select the version that includes insurance payments to get an accurate daily income summary. If the report doesn’t match actual payments, submit a ticket for assistance.

• For secondary claim payments—or additional payments on a primary claim—open the original payment box and select the blue Add Another Check button (bottom right). Enter the payment date, check number, and details. You may also need to adjust patient responsibility and write-offs in the original posting. When finished, update the Superbill by clicking Save and Mark Done.

Analytics

OptiMantra’s analytics tools make it easy to monitor and review your insurance billing activity, helping you streamline workflows and identify areas needing attention. With built-in reports such as insurance aging reports with balances due, reimbursement rate summaries by payer, posted claims without superbills, and EOBs by date of service, you can stay on top of claim statuses, track payment trends, and ensure your billing process remains efficient and accurate.

For more info on Analytics: Learn about Analytics (the basics)

Live Training and Support

Our billing experts are here to help with accurate setup, transmission errors, and payment posting issues. 

For questions, create a ticket within OptiMantra by clicking “Create Ticket” at the top of your home screen. Your ticket will be routed to an insurance billing specialist for assistance.

• We offer drop-in insurance billing sessions via Zoom every Tuesday and Thursday, led by our billing experts. Feel free to join at any time during these sessions.

  • Tuesday sessions are held from 11 AM to 12 PM PST (2 PM to 3 PM EST). 

    • General insurance billing information and setup (click for signup)

  • Thursday sessions are held from 11 AM to 12 PM PST (2 PM to 3 PM EST). 

    • A Q&A format to assist with any questions (click for signup) 
      
       

• If you’re transferring ERA setup from another program using Office Ally, you may need to complete a separate application for each insurance company. For the most up-to-date information, please contact Office Ally directly at 360-975-7000.

Tips for Successful Insurance Billing

• Stay Organized: Keep patient records accurate and verify insurance details before services. Eligibility and registration errors cause about 35% of denials.

• Use a Reliable Billing System: Invest in reliable medical billing software to streamline the process, reduce errors, and track claims accurately. (You’re already doing this!)

• Stay Informed: Monitor policy, coding, and regulation updates to prevent rejections and denials.

• Follow Up: Track claims, address denials promptly, and contact payers if no response is received (30 days for electronic, 45 days for paper). Be mindful of timely filing limits (e.g., Medicare: 1 year).

• Use the Billing Checklist: A detailed daily, weekly, and monthly insurance billing checklist is attached to this article. Use it to stay organized, maintain timely workflows, and resolve claim issues.