If the decision is made to not use an EDR, then great care must be taken to establish protocols that will allow timely submission of accurate charges to payers. Even for those not using an EDR, it may be beneficial to use electronic billing. The critical form that links services provided to the information system and the billing process on a patient-by-patient, day-by-day basis is the encounter form. Also called a charge slip or superbill, it is generated for each patient visit and serves to communicate information about the number and type of services provided and who provided them to the system that generates bills. The health professional signature on the encounter form makes this a legal billing document and attests to the fact that services were performed and may be billed for. Click the links to see samples of encounter forms for those still using paper billing:
Most encounter forms use progress codes that are non-billable until the procedure is completed (i.e. RCTs and prosthetics). Commonly, these are CDT codes with "P" appended, while completed procedures have "C" appended or have no prefix or suffix. The clinic can also create its own dummy codes to signify non-billable procedures.
Depending on coverage, some procedures may need prior approval by the third-party carrier to be paid after completion. Terms for this are usually spelled out in the third-party contracts. After the dentist formulates a treatment plan, it is submitted for prior approval (PA), and approved services and amounts are assigned some kind of code for billing upon completion (often called a PA number).