Canada Claims

For Canada users, in the Account Module, click New Claim, or double-click an existing claim to edit.

To send electronic claims (e-claims), setup the ITRANS 2.0 or Claimstream clearinghouse first.

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 a claim is sent electronically, this box is automatically filled with a unique transaction reference number composed of letters and numbers. To reverse or unsend 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).

Note: After reversing a claim, manually update the claim status back to Unsent. If needed, successfully reversed claims can be deleted and recreated.

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.

Procedures

Up to seven procedures can be included on a claim, per CDA limitations. If sending more than seven procedures, create multiple claims.

Claim Responses and Payments

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

A response may come back in French for a subscriber.

  1. If the carrier has the subscriber's preferred language set to French on their end, then we honor the carrier's information and will display the response in French.
  2. If the subscribers's preferred language is set to fr in the Edit Patient Information window, then we display the response in French, even if the preferred language is English for the carrier.
    Note: In order to display responses in French, a custom language of fr must be added in Language Definitions. Using French will not work.
  3. The disposition and notes on a response come directly from the carrier. Sometimes this information displays in English, sometimes French, and sometimes both. There are no settings in Open Dental to change this.

Also see Canada Insurance Plans.

Substitutions

If a carrier substitutes a code, the substitution code is added as a new row in the Edit Claim window. This allows the user to view the submitted code as well as the substituted code.

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.

Reversals

Claims can sometimes be reversed on the day they are sent. Claims can only be reversed on the same day, by carriers that support claim reversal, and when a Transaction Reference Number is generated (see Canadian Tab above).

If a claim needs to be reversed on a date later than the date it was originally adjudicated, the carrier does not support claim reversals, or a transaction reference number was not generated, the claim must be reversed manually by contacting the carrier.

Automatic Printing

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

A claim form prints automatically in these scenarios:

Responses should be printed or saved immediately after being received. If actions are taken on the claim after receiving the response (such as deleting the claim, changing patient information, updating carrier information, etc), the preview may contain inaccurate information.

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.
  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.

Secondary Claims

If a patient has primary and secondary insurance:

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

Primary preauthorizations are available for carriers that accept them. On the claim form, there is no official box to indicate Preauthorization. The carrier identifies a claim as a preauthorization when there are no procedure dates. To show the word Preauthorization on a printed preauthorization, manually add the field ShowPreauthorizationIfPreauth to claim forms.

Open Dental does not support the electronic sending of secondary preauthorizations (COB predeterminations).

If a patient has dual insurances from the same carrier (i.e. blue-on-blue), the carrier may coordinate secondary coverage estimates automatically and send two responses to Open Dental. These will display one after the other.

Electronic Attachments

Open Dental does not support electronic attachments or narratives (claim notes) at this time.

Troubleshooting

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