Dental

NexSys provides a real time response to dental offices across Canada.  NexgenRx’s sophisticated, leading-edge “rules based” dental claim systems provides plan members, plan administrators and plan sponsors access to online claims processing in real-time. The adjudication process includes a thorough authentication of eligibility, procedure code verification and payment information, and maintains a complete claims history.

If your dentist is registered with CDAnet they are ready to go on our system.  Our systems are compatible for electronic claims adjudication with all licensed dentists across Canada who has CDAnet.  Our qualified staff can also provide manual dental claim adjudication with the same quality and controls as our automated systems.

Some of the features of the NexgenRx dental claims system include:

  • Compatible with EDI submissions originating from CDAnet versions 2.4 or 4.03

  • Customized rules, messages, and frequency limitations

  • Dental professional database

  • General Practitioner (GP), Dental Specialist and Hygienist Fee guides

  • Dental consultant services

  • Dental claim audits

It is always best to check the details of your specific plan before proceeding with any dental services.  Some items may be covered by your dental plan but there are also other rules that may limit the amount that is payable to you. 

For example, your plan may have one of these limitations or even a combination of several of these sample limitations…

  • A maximum dollar limit,

  • A percentage payable from a specific dental category (e.g. 50% of restorative work),

  • Pay based on a prior year’s fee guide,

  • An Alternate Benefit Clause (ABC clause) A provision in a dental plan that allows the third party to base the benefit paid on the fee for an alternate procedure which is less expensive than the one recommended by the dentist,

  • May only cover General Practitioners (no Specialists), or

  • May not cover specific procedures (e.g. no crowns or bridges, etc…)

 

Dental procedures are generally put into three main categories.  Below is a general guideline …

  1. Preventive dental

 The preventive dental care makes available to you (the member) and each person under the plan (your dependents) the following benefits …

  • x-rays, fillings, standard checkup and cleaning
  • periodontics - scaling and root planing which keeps the tartar build up off your teeth
  • minor extractions (procedures that do not require surgical flap or sectioning of the tooth).

 

  1. Restorative dental

Restorative dental care makes available to you (the member) and each person under the plan (your dependents) the following benefits …

  • crowns
  •  dentures
  • repair and adjustments to dentures
  • bridgework
  • surgical services
  • major surgery
  • anaesthesia - when oral surgery is required
  • drug injections
  • laboratory procedures
  • root canals

 

  1. Orthodontics

Orthodontic care is generally available to dependent children under a specific age but some plans     also make this benefit available to you the plan member.  Here are some sample benefits…

  • braces
  • interceptive, interventive or preventive orthodontic services, other than space maintainers
  • diagnostic procedures, formal treatment or retention

 

If you need more help understanding how this benefit will help your group or how to add this to your plan, please contact our sales team or your NexgenRx administrative support rep for more information.  We can definitely help you build a flexible product to meet your needs and within budget.