Members Management

Members Database

Cover/Product Database

Group & Individual Contribution Billing

Agency Administration Module (Optional)

Customer Service Notes System

Correspondence Module Features

Claims Processing Modules

Claims System Versatility

Claims Administration & Assessment

Claims System Summary

Reasonable & Customary Charges

Electronic Claims Processing

Dental Claims Module

Pharmaceutical Processing Modules

Claim Adjustment & Cheques Cancellation

Cheques & Remittances Advice

Report & File Generation



Dental Claims Module
Allows you to override assessment with dental-specific edits
The Dental Module is a complete dental solution.  It allows you to process dental claims and enter details for denied dental procedures.  Benefit lines are validated against system level tables.  Dental logic “stored procedures” review each line item and bundle or unbundled charges as necessary.  The final version of the claim is then processed through assessment where frequency checks may place further restrictions on the covered amount.
Significant Strengths


Allows user-defined parameters under which the module works.  Parameters may be defined at the default (common) level or at the benefit plan level.  

Provides two levels of replacement order – one for deciduous teeth and one for permanent teeth.  

Defines the basic characteristics of each tooth including location and shape.  This information is used to validate that the services performed are appropriate for the particular tooth.  

Allows customised messages (notes) that display during dental claim processing.  

Identifies procedures not covered by the plan.  

Identifies groups of teeth that are treated in the same manner.  For example, all incisors and cuspids might be defined as a tooth grouping for cosmetically appropriate restorations.  

Groups procedures that are related together.  

Defines procedures by categories including examinations; x-rays; fillings; finishing’s; sedatives; packages; endodontics; anaesthesia; extractions; crowns; dentures; periodontal planing; scaling, and equilibration; and models (for orthodontia care only).  

Defines dental logic by Logic Categories and unique data fields dependent upon Logic Categories.  

Allows multiple benefit lines related to a single service (bill).  

Retains historical information.  

Supports the FDI Two-Digit Tooth Identification chart as published in the Australian Schedule of Dental Services by the ADA.  

Allows definition of procedure-specific frequency edits for variable rolling time periods.  This means edits determine how often a procedure may be performed (days, months, years between occurrences) and the maximum number of times the procedure may be performed.



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