Submitted and estimated are two different numbers about the same claim

The two columns

Open a claim in Eaglesoft, or print the report that lists claims by insurance company, and both figures are there, with almost no explanation of which is which. The exact wording on the column headings differs between versions, so read what a figure is doing rather than trusting the label over it. The fastest way to keep them straight is to stop thinking of them as two amounts and start thinking of them as answers to two different questions.

Total submitted

Answers: what did we bill? It is the amount that left this office on that claim, built from the fees on the procedures attached to it. It is a fact about something your office did.

Total estimated

Answers: what do we think comes back? It is the software's prediction of the payer's share, built from the fee schedule and coverage attached to the plan. It is a forecast about something the payer has not done yet.

Once they are read that way, the gap between them stops looking like a problem. The difference is the part of the bill your office does not expect insurance to cover, which is the contractual adjustment you agreed to as a participating provider plus whatever the patient owes as coinsurance or deductible. For an office in network with most of its plans, that gap can be wide, and a wide gap is the normal state of a claim rather than a symptom of anything.

What submitted counts

Submitted is the billed amount. If a claim carries four procedures, the submitted total is those four fees as they went out the door. Nothing about the payer's behaviour is in this number. It is a record of what your office asked for.

What moves it

• Adding or removing a procedure. A line added to the claim before it goes out, or one pulled off it, changes the amount billed because the amount billed is those lines.
• Correcting a fee. If a fee was entered wrong and is fixed before submission, the billed amount moves with it.
• Resubmitting with a change. A claim corrected and sent again carries whatever it now contains. This is also the moment duplicates get created, so a resubmission is worth a glance at whether the original is still sitting open.

What does not move it

• A payment posting. The payer sending money does not change what you billed. It changes what remains.
• An adjustment. A write off reduces the balance on the account. It does not rewrite the history of what was submitted.
• The payer allowing a different amount. An allowed amount is the payer's opinion of the fee. Your submitted total is still what you sent.

That stability is exactly why submitted is the right number behind an aging worklist. It is the amount you are waiting on an answer about, and it does not shift under you while you wait. It is worth being precise about what that means, because the wording matters: a billed amount on an open claim is a signal to review, not confirmed loss and not confirmed collected. Contractual adjustments, patient responsibility and a denial can all still change what finally arrives.

What estimated counts

Estimated is the software's expectation of the payer's share. It is derived from the fee schedule attached to the plan, the coverage percentages for each category of treatment, and whatever the system knows about the deductible and the annual maximum at the moment the estimate was calculated. It is a good faith calculation from the information on file, and that last clause is the whole story.

Three reasons it is often wrong through nobody's fault

1. 1The fee schedule on file is out of date. Plans update their allowables and the update reaches the practice late, or reaches it and never gets entered. Every estimate calculated in between is computed off numbers the payer no longer uses.
2. 2The remaining maximum is unknown. The software cannot see treatment the patient received somewhere else, and it usually cannot see a claim another office has in flight. A plan close to its annual limit will estimate as though there is room.
3. 3The plan applied an alternate benefit. The payer paid toward a different, usually cheaper, procedure than the one performed. No estimate calculated from the submitted code predicts that, because the substitution is a decision the payer made after the fact.

Here is the consequence that catches offices out. In an accounts receivable view, the estimated insurance portion is what gets netted out of an account balance to show what the patient owes. So when an estimate is stale, money moves between the insurance column and the patient column with nobody touching a claim and nothing appearing to change. The account looks like the patient owes less than they do, or more, and the only visible symptom is that a report stops reconciling. The full version of that problem, and what to do about it, is in estimated insurance and your A/R.

When the submitted total is zero

This is the case worth knowing about, because it looks exactly like a data error and it is not. A claim can carry a zero total on its header while the claim plainly has procedures attached to it, each with a real fee. The claim went out, the payer received it, and the header still reads nothing.

When that happens, the real billed amount for that claim is the sum of the fees on its procedure lines. That number is present and correct on the claim. It is only the summary figure that is empty. So any report, export or spreadsheet that reads the header and stops there will show that claim as zero, include it in the row count, and quietly leave its value out of the total.

How to spot it in a few minutes

1. 1Sort your outstanding claims report by amount, ascending. Every zero value claim collects at the top.
2. 2Open one. If it has procedures with fees on it, you have found the case. If it genuinely has nothing on it, that is a different problem and worth its own look.
3. 3Count them and add up the procedure fees. That figure is what your report total is short by.

The reporting consequence is worth stating plainly, because it is the reason this is worth publishing at all. A total built from claim headers can be short by whatever those claims are worth, and there is nothing on the screen indicating that anything is missing. The report does not warn you. It just prints a smaller number than the truth, confidently.

Which one belongs in your A/R

Both, for different jobs, and never mixed. The recommendation is direct.

• For a worklist of what to chase, use submitted. It is what you are waiting on an answer about, it does not move while you wait, and it is the figure a payer representative can look up on their side of the call.
• For a financial expectation of what will arrive, use estimated. It is the better forecast of cash, and it belongs in a projection rather than in a collections queue.
• Label the estimate as an estimate every single time it is shown. A forecast printed under a heading that reads like a fact is how it ends up quoted in a meeting as though it were one.

Two rules follow from that split. Never blend the two into a single figure, because the result answers neither question and cannot be reconciled against anything. And never let two reports in the same office use different ones under the same heading, which is a state an office can be in for years without knowing it. That is what produces the meeting where two people quote the insurance number and both are reading correctly from their own report.