Dental Claims

Dental Claim Adjudication
ESI Canada has one of the most modern and sophisticated dental claim systems in the country. ESI Canada’s systems are available to insurance carriers and third-party administrators. Online claim processing ensures claim accuracy almost instantly. Within seconds, claims are processed to provide eligibility and procedure code verification and payment information. The system also automatically identifies duplicate claims.

The dental system tracks procedures at the appropriate level (i.e., arch, sextant, quadrant, tooth, surface, or dentition) depending on the procedure. The system keeps track of all extracted teeth processed on our system and values incoming claims against claim history.

These are some of the features available in our system:

• Accommodates EDI submissions from anyone using CDAnet versions 2.4 or 4.03
• Customized rules, messages, and frequency limitations
• Ability to support online coordination of benefits (COB) with public and private sector plans
• Cost-plus calculations
• Ability to share common core plans and make exceptions for new plans
• Dental professional database with over 17,000 dental providers.
• Reporting capabilities
• Fee guides from 1987 to the present

ESI Canada also offers its customers these dental services:

• Paper claim processing services
• Cheque and Explanation of Benefits (EOB) printing
• Online dental plan set-up
• Dental consultant services
• Dental claim audits
• Card production
• Bilingual customer service
• Bilingual Call Centre for providers
• Turnkey training solutions

Adjudication Rules
There is tremendous flexibility in the use of adjudication rules. Customers can either: (1) use ESI Canada's standard set of claim processing rules, or (2) have designated users create their own customized rules in a user-friendly Windows-based interface, or (3) use a combination of ESI Canada and customized rules. What's more, rules can be coded without the involvement of information systems staff.

Rules can include:

• Age restrictions
• Frequency limitations
• Alternate benefit clause
• Fee guide parameters

Dental Plan Management
Customers can set up their own dental plans or use ESI Canada's expertise to set-up and manage dental plans. There is also an automated batch process to facilitate plan setup.

Dental Professional Database
ESI Canada maintains a database with information Including more than 17,000 dental providers, their unique identifiers, addresses, specialties, and language of preference. Our comprehensive database includes dental providers who submit using either EDI or paper claims, or practice out of different office locations. For assigned claims, ESI Canada pays dental professionals for the claims they submit to us by cheque or EFT twice monthly. They also receive a detailed statement of submitted claims.

Reporting
Customers have access to comprehensive dental reporting. ESI Canada's reports provide valuable information to manage the dental benefit. Reports are divided into two groups: Productivity Reports and Standard Reports, and are available on demand through a web-based reports menu. Productivity Reports are intended to help our customers manage their day-to-day business and address various aspects of processor productivity and claims processing turnaround. Standard Reports can help our customers monitor claim experience and make plan changes, as needed.

Dental Consultant Services
Dental consultants, who are licensed dentists, are also available to offer their expertise on complex claim issues. For example, dental consultants can review claims or predeterminations to ensure that benefits are paid in accordance with contract wording. Also, upon customer request, dental consultants can provide advice on administrative practices. Our dental consultants also stay informed of changes in provincial legislation and understand industry trends and issues.

Dental Audits
On behalf of our customers, ESI Canada can review claims to ensure accuracy in payment in conjunction with plan and fee guide parameters. Our audits also ensure that claims paid are aligned with customer contracts and adjudication guidelines. ESI Canada participates in a number of industry audit initiatives, including the Canadian Health Care Anti-Fraud Association (CHCAA).

Dental Procedure Database
On behalf of our customers, ESI Canada maintains a database containing more than 1,400 different fee guides based on province/territory, specialty and year. Our historical fee guides date back to 1987. In addition, ESI Canada maintains an extensive series of conversion tables mapping specialist procedure codes to general practitioner codes, and Canadian Dental Association (CDA) codes to Association des chirurgiens dentistes du Québec (ACDQ) codes.

ESI Canada's dental claim experts evaluate the suggested fee guides published each year by the Canadian Dental Association and each provincial association, including specialist, denturist and general practitioner codes. On behalf of our customers, they evaluate coverage of new codes and provide coverage recommendations based on their knowledge of industry standard contract wording and customer-specific administrative guidelines.