Fast, Reliable Health and Dental Claims Management

When it comes to health and dental claims management, ClaimSecure matches reach and rigour with speed of service. Our real-time adjudication system is connected to 99% of all licensed pharmacies and 80% of licensed dentists across Canada. To ensure accuracy, our system performs more than 100 checks and edits on all electronically transmitted claims before they are accepted, adjusted or rejected, and adjudication results are immediately transmitted back to both claimants and service providers in real time. When it comes to offering convenience and efficiency, we take the lead.

In the case of extended health care (EHC) claims – including vision care, major medical, hospital and out of country and travel assistance benefits -- we adjudicate, process and pay eligible claims within five business days of receipt, which leads to happy plan members – and happy plan members are happy employees.

Key Features

  • National Coverage - No matter where in Canada plan members may be, ClaimSecure has them covered for health and dental.

  • Rigorous Standards – Our drug and dental claims management system is designed to ensure that member/dependant eligibility, therapeutic choice, procedure code eligibility and cost containment measures are strictly adhered to. Furthermore, ClaimSecure has developed extensive auditing procedures and guidelines that help protect clients from fraudulent claims and/or abnormally high healthcare provider service fees.

  • Speed and Functionality – For drug and dental claims, our state-of-the-art adjudication system allows for electronic claims submission directly by the health service provider. Patient history is reviewed and claims are approved, adjusted or declined online in real time within mere seconds. All transaction data is then stored in our central data warehouse for reporting, invoicing and analytics. How’s that for offering peace of mind?

Flexible Plan Design Options

Choose a standard plan design or create a customized program to ensure your organization’s unique needs are met.

Drug Claims :

  • Generic substitution
  • Preferred provider network
  • Tiered co-payment: brand vs. generic; government vs. private; pharmacy chain
  • Therapeutic price substitution
  • Managed cost formularies
  • Deductibles and maximums
  • Coordination of benefits – private and provincial

Dental Claims :

  • Pay member or pay provider claims payment options
  • Tiered co-insurance per benefit class (e.g. 100% basic, 80% major restorative, 50% orthodontics)
  • Co-insurance plus calendar, policy or lifetime maximum per benefit class (e.g. 100% periodontics to maximum of $500/year)
  • Annual or per-claim deductibles
  • Maximums:
    • Annual
    • Per certificate
    • Per individual
    • Per benefit class (e.g. endodontics)
  • Coordination of benefits

EHC Claims :

  • Tiered co-insurance per benefit class (e.g. 100% Hospital, 80% Major Medical)
  • Co-insurance plus calendar maximum per benefit class – dollar or frequency (e.g. 100% Paramedical to maximum of $500 per year or 12 visits per year)
  • Dollar maximums: Lifetime or Annual (per certificate, individual or benefit class)
  • Benefit entitlement age maximums (for students, employees, retirees)
  • Pay member/provider capabilities
  • Usual and customary price verification
  • Coordination of benefits – private and provincial (e.g. Assistive Devices Program)
  • Front-end deductibles