E-Claims

Electronic claims are sent and received using the standard EDI X12 837 data format.

In dentistry most e-claims are sent to a clearinghouse before being sent to the insurance company. Some big payors, like Medicaid, do offer direct connections.

For troubleshooting, see Clearinghouse Error Messages. For more technical information about what is sent in e-claims, see E-Claim Complexities.

Clearinghouses

Clearinghouses differ greatly in size, infrastructure, and business model. Some are small and tend to serve a local geographic area or focus on customer service. Some are actively pursuing more direct connections with payors. Some clearinghouses are more accurately described as aggregators, having a direct connection to only a few payors and sending the bulk of their claims to another clearinghouse.

Recommended Clearinghouses:

Additional clearinghouses and aggregators that are known to work well with Open Dental.

Other: These are clearinghouses or aggregators that we have had some complaints about but may work fine with Open Dental. We do not know.

Renaissance E-Claims (not X12 format)

Canada:

Direct Connections to Payors

Most payors prefer to use clearinghouses so they do not have to maintain direct connections with thousands of dental offices. However, some do offer direct connections. To use Open Dental for direct submission, there is work involved including: contact the payor, get their implementation guide, set up a partnership agreement, test, and finally upload claims. We do not provide implementation details and leave it up to individual offices. But it can still be useful for very large volume offices. The X-12 files will typically need to be manually uploaded to the carrier because there is no standard for transport.

The carriers below are also known to accept X-12 claims, but we have not had time to do any testing with them yet. Remember that we have no time line for this functionality and it might never even happen.

Updating to 5010 Format

Clearinghouses began accepting the 5010 format on 1/1/2012. To use the 5010 format:

  1. Use version 11.1.16 or later (Inmediata users, use version 11.1.30 or later).
  2. Edit your clearinghouse to use the 5010 format.
  3. Monitor your reports for dropped claims or other problems.

For information about rejections due to Billing Provider PO Box, see E-Claims Complexities under the PO Boxes subheading.