Our health claim adjudication module is flexible with respect to plan design. Deductibles, copays, and coinsurance can be set at almost any level. In addition, adjudication rules can be set at any benefit level, including items such as laboratory work, radiographs, durable equipment, orthotics and orthopedic shoes, and nursing.

Health Plan Management
ESI Canada has medical consultants who will provide their expertise on more complex claims issues. For example, consultants will review all referrals received with claims and provide advice on administrative practices to ensure claims control. In addition, health-claim consultants will work closely with medical consultants and our customers to ensure that we have appropriate procedures in place. Our health-claim consultants will also review reasonable and customary (R & C) limits on service items, keep informed of changes in provincial legislation, establish administrative guidelines, and understand industry trends and issues.

Health Benefit Utilization Review
ESI Canada has developed its own recommended referral guidelines to ensure cost-containment and proper adjudication of claims (e.g., specific information is required for nursing equipment, etc.). We rely on our medical consultants and industry standards to develop these guidelines. We can adjudicate claims based on our guidelines or the guidelines established by our customers. Various techniques, including our extensive profiling capabilities, are used to verify that claims are paid for authorized procedures only. These claim verifications detect and prevent inappropriate billing practices. There are also tight controls on assignment privileges. ESI Canada participates in a number of industry audit initiatives, including the Canadian Health Care Anti-Fraud Association (CHCAA).

Provider Network Management
ESI Canada has a provider database that contains information such as registration numbers, addresses, and specialties.

Reporting
Customers will have access to comprehensive reporting that provides valuable information to manage extended health benefits, including the ability to identify trends, monitor the results of claim controls, and help make well-informed decisions. Reports will be available by group, healthcare provider, or health procedure. An electronic data feed will also be available so customers can download claim information for manipulation and integration into their overall information processing activities.

Reasonable and Customary Limits Database
The health claims system will accommodate various reasonable and customary (R & C) limits in each province. ESI Canada's medical consultants keep abreast of R & C limits for various healthcare services. This involves obtaining information from provincial paramedical associations and researching standard pricing on items such as durable equipment and nursing services.