Product

• Vision – Preferred Provider Network option available
• Hospital
• Major Medical
• Out-of-Country

In Canada, ClaimSecure and other industry stakeholders are working towards the automation of the processing of these claim types; however, today they are almost entirely paper based.

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Features

Flexible Plan Design Options

• Tiered coinsurance per benefit class (e.g. 100% Hospital, 80%, Major Medical)
• Coinsurance plus calendar maximum per benefit class – dollar or frequency (e.g. 100% Paramedical to maximum of $500/year or 12 visits per year)
• Dollar maximums:
  • Lifetime
  • Annual
    • Per certificate
    • Per individual
    • Per benefit class (e.g. Medical Equipment)
• Benefit entitlement age maximums
  • Students
  • Employees
  • Retirees
• Health Care Spending Account (HSSA) set up/maintenance
• Pay member/provider capabilities
• Usual and customary price verification
• Coordination of benefits – private and provincial (e.g. Assistive Devices Program)
• Front end deductibles
• Multiple trip duration options (OOC)

Usual and Customary Adjudication

If required, ClaimSecure has the ability to adjudicate EHC claims according to Usual and Customary (U&C) fees.

The service fees payable under U&C adjudication is tracked on a National basis and is updated annually. ClaimSecure maintain U&C tables for various services utilizing the following methods:

• Information sharing with other adjudications
• Practitioner Association published guidelines
• Website price list of suppliers
• Book of business claims experience
• Provincial Assistance Programs

Please speak to a ClaimSecure representative to learn more about the benefits and limitations of the U&C adjudication option.

Auditing Program

ClaimSecure has developed extensive auditing procedures and guidelines. These procedures protect the client from fraudulent and/or abnormally high service fees being charged.

These include:

• Issuance of customized identification card with unique certificate numbers
• Mandatory requirements of original receipts
• Random Provider phone audits
• Healthcare Advisory Panel review of questionable claims
• Individual dollar maximum approval guidelines by claim processor
• Usual and customary claim guidelines

ClaimSecure auditing procedures often differ by claim type. For example, for provincial Hospital claims, ClaimSecure performs the following checks and edits prior to payment approval:

• Verification of claim – contact hospital to confirm patient required hospital bed
• Same day edit – confirm whether patient was released on the day of treatment.
• Supervisor override code required for claims in excess of specified dollar limit.
• >5 day stay – confirm whether weekend fees were charged for stays greater than 5 days.
• Private room charge – check hospital bed policy. No charge is applied if hospital only has private rooms available. Also, confirm that private room was requested versus semi-private.
• Pre-payment audit required before approval
• Client questionnaire – verifies if room upgrade was requested by the patient.
• Physician letter – verifies if the upgrade was medically necessary

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Functionality

To submit a claim, covered members and/or dependents are required to pay out-of-pocket and submit the original claim receipt, along with identifier information, to ClaimSecure for processing. If the Provider accepts assignment (agrees to invoice ClaimSecure directly), ClaimSecure will issue payment directly to the Provider on behalf of covered members.

Currently, EHC claims are submitted in a paper reimbursement environment and processed within five (5) business days of receipt.

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