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Dental Suite

The Enterprise System Dental SuiteSlide3.png

Built from the ground up by dental industry experts, our dental suite is designed to efficiently administer both Medicaid and commercial dental benefit programs. The system comes preconfigured with dental-specific terminology, procedure codes, business rules, real-time dashboards, and on-demand reports, all based on dental industry best practices.

The system can easily be scaled up or down to meet to meet your unique membership and claim volume needs.

The Enterprise System Dental Suite offers a comprehensive set of administrative functions, including:

  • Enrollment & eligibility
  • Fee schedule management
  • Flexible reimbursement methods
  • Benefit plan design & maintenance
  • Claim data entry
  • Claim editing, adjudication, & payment
  • Customer service
  • Provider network management
  • Premium billing
  • Reporting

With the Enterprise System Dental Suite, you can continue to use the features in your existing system that work well for you. Choose only the Dental Suite functionality that you need; we’ll integrate seamlessly with your existing system. You decide how you want to put the Enterprise System Dental Suite to work – and we’ll make it happen.

Features & BenefitsSlide4.png

The Enterprise System Dental Suite is a fully integrated application package specifically designed to meet the needs of dental benefit administrators.

Web portals

Real-time data, drawn directly from the Enterprise System, can be made available through self-service web portals. For example, dentists can quickly check patient eligibility for services, submit claims, and review Remittance Reports as soon as claims are paid. Web portals help minimize hand-written paper documents, faxing, printing, postage, and support calls. Every question answered through a web portal means one less phone call to support staff.

Dental-specific dashboards

Real-time dashboards give you quick access to up-to-the-minute data as well as insight into trends over time. Use dashboards to analyze:

  • Claim and authorization volumes, history, and trends.
  • Claim and authorization utilization statistics and summaries.
  • Enrollment statistics and trends.
  • Premium billing statistics and trends.
  • Provider reimbursement paid claim dollars and trends.
  • Provider/patient distributions.
  • Provider profiling.
  • IBNR calculations.
  • Benefit loss ratios and trends.
  • Self-funded account paid claim dollars and claim cost per subscriber summaries and trends.
  • Customer service call volumes.

Paperless workflows

The Enterprise System is designed to support paperless workflows with its web-based architecture, built-in document management system, and fully integrated self-service web portals.

Data file imports. The Enterprise System can import and process electronic data file loads in HIPAA-compliant version 5010 transaction set format and in its own proprietary file import format. Automated processing rules can be easily defined and managed through the user interface. And detailed Companion Guides and file format layouts are just a click away in the Online Help Reference Library.

Integrated document management system. Taking advantage of our integrated document management system can minimize or eliminate your third-party document storage and retrieval fees. Electronic documents in nearly any standard file format can be attached and retrieved for instant online review throughout the system. For example, electronic health records and x-rays can be attached and included with a patient’s comprehensive claim history. Selected documents can also be made available through self-service web portals.

Flexible reimbursement methods

Go beyond traditional Fee-For-Service reimbursement. Design flexible reimbursement plans based on a variety of reimbursement methods and flexible calculation rules to determine how much to pay for each service performed.

Tightly integrated authorizations and claims

A key strength of the Enterprise System Dental Suite is tight integration between authorizations and claims. For example:

  • Authorization/claim reviews, including prior reviews for medical necessity, can be performed before claims are processed for payment. During claim processing, additional business rules can perform post reviews.
  • Requirements for supporting documentation can be set up and enforced through the system, with automatic administrative denials when required documentation is not submitted.
  • Authorizations are logged and automatically linked with associated claims. As claims are processed, authorizations are automatically consumed (decremented).
  • Authorization and claim history, statistics, and trends are instantly available in real-time dashboards.

Customer Service features

The Enterprise System Dental Suite Customer Service features give call center staff the tools they need to respond quickly and accurately to inquiries from members and providers. Features include a complete call history for every logged communication and follow-up response, as well as detailed on-demand reports and dashboards about call history trends and performance statistics.

Call center staff have the resources they need, right at their fingertips, to:

  • Research and answer questions about benefits, claims, pre-treatment estimates, and eligibility.
  • Find a dentist or specialist for a member and provide office hours, languages, and driving instructions.
  • Review supporting documentation attached to claims.
  • Verify PHI access permissions.
  • Assign a follow-up call to another staff person or department and send an email alert.
  • Create a follow-up work queue.
  • Handle requests for out-of-network providers.
  • Reset web portal passwords and unlock accounts.
  • Generate comprehensive call history and provider request reports.

Focused cost-containment features & utilization management

The flexibility of the Enterprise System Dental Suite allows each insurer to chart its own path toward containing costs and managing utilization without sacrificing provider and member satisfaction. This targeted, individualized approach reduces administration costs for most providers while allowing you to focus your clinical resources on only those treatment patterns that warrant closer evaluation. A few of the Dental Suite tools include:

Customizable dental edits and business rules. The Enterprise System uses these rules to identify and automatically approve or deny services for administrative reasons where appropriate, and to trigger exceptions for review during claim and authorization processing cycles.

Clinical algorithms that can be applied down to the individual provider level, based on historical analysis and profiling results. These clinical guidelines can then used by dental review specialists and dental consultants to ensure consistent authorization determinations. These guidelines can be made available to providers through a web portal, so participating dentists can follow the decision matrix and understand the logic behind authorization decisions.

Dental reviewer efficiency monitoring. The efficiency and results of each dental reviewer can be monitored and analyzed by a number of parameters, including turnaround times, number of approvals, number of denials, reviews by code, reviewer denial rates, and savings amounts. A consistent approach to authorization determinations promotes clarity and transparency for providers, which in turn reduces provider participation costs and client administrative costs.

Provider profiling & data analysis reporting. The Enterprise System Dental Suite includes a sophisticated provider profiling tool to assess practice patterns and identify outliers. The system provides access to hundreds of customizable data analysis reports to help manage benefit costs and identify areas of potential utilization management review.

Download our Dental and Vision Suite Brochure