Product

This claims management system requires that every electronically transmitted dental procedure pass through rigorous checks and edits prior to the dental claim being accepted, adjusted or rejected.

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Features

Flexible Plan Design Options

• General Practitioner (GP) and Specialist Fee Guide Adjudication
• Pay member or pay provider claims payment
• Standard plan designs or totally customizable dental programs
• Reference based pricing – e.g. pay up to the amount of a certain procedure
• Tiered coinsurance per benefit class (e.g. 100% basic, 80% major restorative, 50% orthodontics)
• Coinsurance plus calendar maximum per benefit class (e.g. 100% periodontics to maximum of $500/year).
• Front end deductibles
• Maximums:
  • Annual
  • Per certificate
  • Per individual
  • Per benefit class (e.g. endodontics)
• Coordination of benefits - private and provincial

National Coverage – Percentage of Dentists Submitting Electronic Dental Claims

ClaimSecure’s card is recognized and accepted throughout Canada. ClaimSecure has partnered with the Canadian Dental Association (CDA) and the Quebec Dental Association (ACDQ) to utilize the most advanced communication protocol available – Canadian Dental Association Network version 4.02 (CDAnet ver.4.02) when performing real-time claims management services.

Dental claims that are submitted by providers and members on a reimbursement basis are also subject to the same standard of checks and edits normally applied to electronically transmitted claims.

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Functionality

ClaimSecure’s dental management system is designed to ensure that member/dependent eligibility, procedure code eligibility and cost containment measures are strictly adhered to within each dental office.

To utilize the system, the covered individual simply presents the ClaimSecure pay-direct health card at the dental office after services have been rendered. The dental provider keys data directly into their practice management software and electronically submits the claim detail to ClaimSecure for adjudication. Within seconds, the dental provider is sent:

• Acknowledgment of claim receipt
• Confirmation of the eligibility of the procedure(s)
• Acknowledgment that the claim is being paid or adjusted (with explanation)
• Required data to enable the dentist to produce an Explanation of Benefit (EOB) for the patient
• Customer out-of-pocket expenses are limited to deductible or co-payment.

All transaction data is stored in the central data warehouse for reporting, invoicing and future data mining.

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