Canada Claims

To send electronic claims (e-claims), setup the ITRANS or Claimstream clearinghouse first. To troubleshoot claims, see Canada Claim Troubleshooting.

Edit Claim Window

To open the Edit Claim Window, in the Account Module, click New Claim, the New Claim drop down menu or double-click on an existing claim.

If insurance requires student school and status, enter it on the Edit Patient Information Window under Name of School and Eligibility Excep. Code.

Canadian Tab

The Canadian tab contains specific Canadian information.

Referring Provider

Accident Date: Used to indicate that dental treatment was needed as the result of an accident. If a value is entered, the Is Accident field on the printed claim will automatically be marked.

Trans Ref Num: When claim is sent electronically, this box is automatically filled with a unique transaction reference number composed of letters and numbers. To reverse or undo a claim, click Reverse. This button is only enabled when the claim has already been sent earlier that same day (determined by the existence of the Trans Ref Num).

Materials Forwarded (email, correspondence, models, X-rays, images): Indicate the types of supporting documents which have been physically mailed to the insurance carrier. These boxes can be checked/unchecked independently.

Treatment Required for Ortho: Only used for Ortho claims. If checked, the ortho flag is sent.

Ortho Treatment (Predetermination Only): Only for predetermination claims, not regular claims.

Maxillary Prosthesis

Mandibular Prosthesis

Extracted Teeth: List of the patient's extracted teeth. For display only. Change the extraction status of teeth in the Chart Module.

Missing Teeth: List of the patient's missing teeth. For display only. Change the extraction status of teeth in the Chart module.

Enter Lab Fee Payments and Write-offs

Lab Fees show in the Procedures grid on the same rows as the procedures they are attached to, see Edit Procedure Canada Tab. To enter lab fee insurance payments and write-offs:

  1. Enter the Insurance Claim Payments (By Procedure).
  2. Enter the Ins Pay amounts for each procedure.
  3. Click Write-Off to automatically calculate any write-off or lab fee payments (amounts in excess of the procedure's billed fee). This message will show.
  4. If a procedure's payment is more than the procedure's Fee Billed:

    Click Yes. The Ins Pay amount for the procedure will revert to the Fee Billed amount, and any excess amount will be automatically applied towards a Total Payment line item when you close the Enter Payment window. Paid amounts will list under Ins Pay, unpaid amounts will be applied as a write-off.

    If you click No, since there are no write-offs, no changes will be made.

    If a procedure's payment is less than or equal to the procedure's Fee Billed, you have two options:

    • Click Yes to apply procedure write-offs to the procedure and automatically create a Total Payment line item for lab fee write-off amounts when you close the Enter Payment window.
    • Click No to apply procedure write-offs to the procedure only. Then close the Enter Payments window and manually enter a new (by Total) payment for the lab fee write-offs. You might also click No if there are no lab fees for the procedures (and thus no need for a lab fee write-off).

    You can enter multiple (by Total) insurance payments (e.g. one for each lab fee).

E-Claims and Sunlife

When sending e-claims, both the treating dentist and billing dentist are submitted. If using the Canadian insurance carrier Sunlife, the treating dentist will receive the payment instead of the billing dentist. This is a decision made by Sunlife and out of our hands.

Reversals

When a non-preauth claim is sent and adjudicated electronically, a Transaction Reference Number is generated (see Canadian Tab above). Claim reversals require a valid Transaction Reference Number so that ITRANS and/or Claimstream know without a doubt which claim is being reversed. ITRANS/Claimstream do not allow claims to be reversed on any date other than the date they were originally adjudicated.

If a claim needs to be reversed on a date later than the date it was originally adjudicated, then the claim must be reversed outside of Open Dental. Once reversed, it should then be manually deleted from Open Dental so that the patient account is accurate.

Not all Canadian insurance carriers support claim reversal. If you attempt a claim reversal for a carrier that does not support reversal transactions, after clicking the Reverse button, Open Dental will display a message informing you that reversal transactions are not supported by the carrier. In some situations, a carrier may choose to reject a claim reversal even when the transaction reference number and reversal date are valid, and when this happens, the only way to reverse the claim is manually.

Automatic Printing

ITRANS/Claimstream require automatically printing patient copies of certain forms in very particular circumstances. Dentist copies are never automatically printed. A single patient copy of a response from ITRANS/Claimstream automatically prints immediately in the following situations:

A claim prints automatically in these scenarios:

Responses can be reprinted later via the Edit Claim window by clicking History, Print.

Some offices find the extra printing less useful than others. There are a few options if you do not want to automatically print copies:

  1. On each computer where claims are typically processed, set the default claim printer to a PDF printer. In version 14.1.6 and greater, the default claim printer is set in File, Printers, Claims.
  2. In File, Print, Claims, select the Prompt option. Then you will be prompted before printing begins and have the option to cancel the print job. See Printer Setup and Troubleshooting.

Secondary Claims

To create a secondary claim, select the procedures, then click the New Claim dropdown, then click Secondary.

If the patient's primary and secondary insurance is with the same carrier:

If the patient's primary and secondary insurance is with different carriers:

There are two electronic message formats for Canadian claims, version 02 and version 04.

It is best practice to first create the primary claim and send it or print it before worrying about the secondary claim because sometimes the secondary claim will be created and possibly sent electronically and automatically.

Preauthorizations

Open Dental does not support the electronic sending of secondary preauthorizations.

Electronic Attachments

The message format for electronic claims is designed to allow electronic attachments for carriers that support version 04 of the standard. As of the writing of this paragraph, no carriers are currently supporting electronic attachments. Open Dental will not be able to send electronic attachments through ITRANS until more carriers can accept them. The format is technically known as transaction type 09 and the response is known as transaction type 19.

Claim Responses and Payments

When you send a claim electronically, you will get one of three possible responses:

Also see Canada Insurance Plans.