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Dental Claims Processing System


SSI's On-line Dental Claims Processing System is capable of handling the needs of a Dental Benefit's plan administrator. The system is designed with menus which allow the users to easily select the task he or she wishes to perform. The entry screen is a prompted, fill-in-the-blanks operation which guides the user through each transaction. The time to learn any transaction type has averaged under one hour.

The Dental Claims Processing System is designed utilizing a tooth charting table. Allowing the user to track work performed by tooth number, tooth surface and by quadrant. The system will track internal limits, frequency limits, dollar limits, benefit or calendar year limits and lifetime limits

The programs provided in SSI's Dental Claims Processing System perform the following functions:

1. DENTAL BENEFIT PLAN FILE MAINTENANCE

This function stores and maintains the various benefit levels and descriptions of each particular Dental Plan in the system. This allows the user total flexibility to handle multiple plans within the system, selecting various categories to complete a plan, such as:

Plan number
Type of benefit category - i.e. Preventive, Radiology, Restorative, Oral surgery, Endodontic, Periodontic, Prothesthetic, Orthodontic, etc.
Plan year deductible:
Member
Family
Family Limit

Calendar year deductible:

Member
Family
Family limit

Carry-over deductible
Benefit category deductible
Coinsurance %
Stop-Loss amount
Benefit category coinsurance %
Pre-authorization

1. DENTAL BENEFIT PLAN FILE MAINTENANCE (continued)

Pre-authorization amount
Automatic exclusion codes
Plan year maximums
Calendar year maximum
Lifetime maximums

2. ADA PROCEDURE FILE MAINTENANCE AND LIMIT TABLES

These functions store and maintain any basic tables used in the automatic calculation of benefit payment, including:

ADA procedure code
ADA procedure description
Up to 5 fee schedule amounts by ADA procedure
Frequency and dollar limits by category
Discount for preferred dentists
Management review required code

3. DENTIST FILE MAINTENANCE

This function maintains a file of all dentists, including:

Dentist social security number/tax ID number
Dentist name and address
Routine assigned or non-assigned payment status
Fee schedule elected or discount for preferred dentists
Management review required code
Certification indicator
Approval indicator
Do Not Pay indicator
An area for free form comments and notes.

4. CLAIM ENTRY

This function enables the user to enter claims into the system for future payment. The system automatically compares service dates with eligibility dates and rejects services performed during periods not eligible. Various other on-line editing is done during Claim Entry, such as management review required and benefit maximums. Other editing is done during the claim evaluation process to improve examiner productivity on-line and allow for internal auditing and quality control.

Information entered includes:

Claim number
Member
Patient
Dentist
Assignment or non-assignment of payment override
ADA procedure code
Description of ADA procedure performed - automatic prompt
Service dates
Teeth
Tooth surfaces
Dentist charges
Amount payable by fee schedule or preferred dentist discount - automatic prompt
Amount charged to deductible - automatic prompt
Reason code for override of normal scheduled payment
Reason code for rejection
Reason code for pending
Other insurance company payment (automatic COB calculations)

In addition, the Claim Entry function allows the user the ability to enter claims paid prior to automation for history only, including appropriate accounting data, i.e. check number, check date, amount of check. This also provides for an excellent training method.

5. DAILY CLAIM LOG

This function produces a printed transaction log of claims entered each day, showing:

Member
Patient
Dentist
Dentist's charge
Amount payable by plan
Number of ADA procedures in claim
Examiner ID
Total number of claims entered
Total amount payable to members
Total amount payable to dentists
Override indicator
Management review required code

6. REJECT / PEND / CATEGORY CODE MAINTENANCE

This function maintains a file of user defined codes that include such information as:

Reject codes and descriptions
Pending codes and descriptions
Major category codes and descriptions
Evaluation limit codes and descriptions

7. CLAIM EVALUATION

This function performs the automatic adjudication of ADA procedures based on frequency and/or dollar limits, as well as other editing. This function automatically creates a quality control worksheet for auditing prior to printing checks.

8. PRE-CHECK REGISTER

This function, which is run prior to check printing, provides the user with a complete audit trail of all claims to be paid. It shows the appropriate totals of checks to be issued and the total number of claims for audit comparison to daily claim logs and actual check register. This also enables the user to transfer funds to the appropriate checking account only when necessary.

9. CHECK AND EOB PRINTING

This function prints checks and detailed explanations of benefits to members and dentists. This function allows the user flexibility to issue checks/EOBs,, combine or separate, as well as one check to a provider for multiple members with the appropriate audit trail supporting the check. Various information is printed, including:

Member name, address and social security number
Patient name and relationship
Dentist name and address
ADA procedures performed by category
Dates ADA procedures performed
Amount charged
Amount payable by plan
Amount charged to deductible
Employer or shop name and number
Other insurance company payment data

10. CLAIM HISTORY DISPLAY AND PRINT

This function is used to display or print the claim history of a member and his or her dependents.
This includes all information entered for a claim, plus:

Check number
Check date
Check amount
Summary of deductible (individual and family)

10. CLAIM HISTORY DISPLAY AND PRINT (continued)

Benefit credit amount
Summary totals by category and year-to-date
Benefit credit accumulated year-to-date

The system is designed to maintain on-line history for as many years as desired.

11. CHECK REGISTER PRINT

This function prints a register of checks, showing:

Check date
Payee
Member's social security number
Check number
Check amount
Claim number
Total amount of all claims paid

12. MANUAL CHECK WRITING AND VOIDING

This function permits the entry of manually written check information, including:

New check number
New check date
New check amount
VOIDed information

13. MANAGEMENT AND STATISTICAL REPORTS

This function produces management reports, including reports containing information concerning:

Benefit utilization by:
Deductible status report
Carry-over deductible credits
Benefit maximum reached
COB savings report
Dollars charged versus paid
Number of claims
Number of ADA procedures
Number of spouses
Number of dependents
Number of members
Total number of patients
Fee schedule selected

Utilization by employer
Utilization by ADA procedure
Dentist profile showing by dentist:

ADA procedure performed
Date ADA procedure was performed
Member on which ADA procedure was performed
Dollars charged versus paid

Pended claims by reason code and aging
Rejected claims by reason code
Service performance report
Examiner productivity report

Reports can be produced and selected for any period of time and by user defined categories.

14. CLAIM DELETE

This function is used to delete from the system an unpaid claim that was entered in error.

15. CLAIM CHANGE

This function is used to change the information about an entered claim after reviewing quality control worksheets, including:

Patient
Dentist
Assignment or non-assignment of payment override
ADA procedure code
Description of ADA procedure performed - automatic prompt
Service date
Teeth
Tooth surfaces
Dentist charge
Amount payable by fee schedule or Preferred dentist
Discount - automatic prompt
Reason code for override of normal scheduled payment
Reason code for rejection
Reason code for pending
Other insurance company payment (automatic COB calculations)

16. CLAIM FILE PURGE AND CLAIM HISTORY FILE UPDATE

These functions are used to purge and reorganize files when management determines on-line history serves no further useful purpose due to aging.

17. DENTIST TOTALS AND 1099's

This function is used to produce reports on the claims paid for each dentist on file. This function also produces printed 1099 tax forms.