NDEDIC Workgroups

Work Group 1 - Eligibility and Benefits 

Through a consensus building process, this work group is responsible for advancing the growth and adoption of electronic eligibility benefit inquiries submitted via the ANSI ASC X12 270/271 transactions.

  • Co-Chair: Kristina Steece, Manager, Customer Connections & Operations - Ameritas
  • Co-Chair: Chris Clelland, Senior Manager, Enterprise Applications - Pacific Dental Services
  • Monthly Meeting: Fourth Thursday of each month at 2:00 pm Eastern/11:00 am Pacific (Join)

About Eligibility and Benefit Transactions

Dental practices, insurance companies and clearinghouses can exchange information electronically about a patient’s dental insurance coverage through two standardized EDI transactions. The ASC X12 270: Eligibility, Coverage or Benefit Inquiry is the request transaction and the ASC X12 271: Eligibility, Coverage or Benefit Information is the response transaction.

Both transactions were developed by ASC X12 for use in healthcare overall. NDEDIC is helping the dental industry adapt and implement the transactions to meet information exchange needs specific to dental.

Adapting to Complexity of Dental Benefit Design

NDEDIC’s Eligibility/Benefit Work Group analyzes unique dental benefit plan designs and benefits/payment administration to identify ways of standardizing information for effective exchange through the ASC X12 270/271. The complexity in dental plan designs requires the exchange of much more detailed information about a patient’s coverage than what is required by the ASC X12 270/271.

New Dental Industry Guide!

Through the work group process, NDEDIC has transformed the Top 50 questions into a guidance document for the ASC X12 270/271. The Top Dental Eligibility and Benefits Questions Response Guide is a list of standard eligibility and benefit questions that large group providers agree would minimize time consuming phone calls if the questions are answered in the payer response. This Guide is currently available for free to NDEDIC members on the Member Portal or available for purchase at the official NDEDIC store.

Work Group 2 - Remittance

Through a consensus building process, this work group is responsible for advancing the adoption of electronic remittance primarily through the creation of best practice guidelines for the ANSI ASC X12 835D transactions.

  • Co-Chair: Dan Vu, Supervisor, Business Analysis, Integrated Delivery Support, United Concordia Dental 
  • Co-Chair: Preston Bryant, Manager of Implementations, RMS
  • Monthly Meeting: First Tuesday of each month at 2:00 pm Eastern/11:00 am Pacific (Join)

Expedited remittance information and faster payment are key benefits of using an electronic version of an Explanation of Benefits (EOB) document. The ASC X12 835 Claim Payment /Advice transaction enables dental providers and payers to exchange enhanced EOB information electronically. This includes information on charges experienced during a patient encounter, amount the payer is remitting to the provider, contractual adjustments, and any reasons the charges might have been denied.

The ASC X12 835 was developed for use in healthcare overall. NDEDIC is working to make the ASC X12 835 optimally useful for the dental industry, thereby also increasing adoption.

Orthodontic Claim Remittance Best Practices Guide

The work group has finalized the development of a guidance document for the ASC X12 835 transaction for a unique business scenario. Dental providers of orthodontia services often submit one claim and dental payers remit payment to the provider over time.

Today, the remittance reporting does not adequately inform the practice of the time frame and frequency of the deferred payments, along with details of the patient and plan’s financial responsibilities. This guide provides detailed recommendations for a wide array of calculations the dental payer performs and how this maps to the ASC X12 835 transaction. This guide is currently available for free to NDEDIC members on the Member Portal and available for purchase at the official NDEDIC store.

Best Practices Guide for the Use of CARCs and RARCs

NDEDIC’s Remittance Work Group develops best practice guidelines for implementing the ASC X12 835 in dental claims processing promoting the consistent use of Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs). Inconsistent use of the CARCs and RARCs by payers can hamper use of the electronic transaction by dental offices.

The NDEDIC work group is soliciting input from the dental industry to identify an inclusive list of current dental Explanation of Benefits (EOB) messages and the CARCs and RARCs that best map to those messages. The goal is to develop a standardized mapping process.

If there are cases where existing CARCs and RARCs lists do not meet dental EOB needs, the work group will facilitate the process of requesting new codes and develop a Best Practices Guide for the Use of CARCs and RARCs. National committees review the codes regularly and Washington Publishing Company publishes updated code lists three times a year.

The work group will continue to update Best Practice Usage Guidelines for use of the ASC X12 835 in dental claims processing and collaborate with ASC X12 on recommended changes.

Work Group 3 - A.I. Processes in Claim Review

Through a consensus building process, this new work group is responsible for defining a mechanism to annotate a claim related to:

    • Whether Claim Review was performed;
    • By whom it was reviewed;
    • Identification of the review's details; and
    • The review summary's recommendation

The Work Group will also define a mechanism to return the same information in responses to claims (claim status or ERA), define identities of claim reviewers (A.I. processes, human reviewers, etc.), and explore the creation of technical guidance documents and registries. 

  • Chair: Tom Mort, Senior Director of Product - Vyne Dental
  • Monthly Meeting: Third Tuesday of each month at 4:00 pm Eastern/1:00 pm Pacific (Join)

About the Role of Artificial Intelligence in Claim Review

The Dental industry is moving forward with new tools and technologies to make efficiency strides claim review. The nature of the work is new and being put through its paces and all parties in review are learning to trust the results. Trust is the key to the successful implementation of these technologies. This is the right time to work towards standards that can provide insight into the processes that have run and what recommendations are available. NDEDIC can play a crucial role in in making that information available in EDI transactions. Work Group 3 aspires to unite the industry to publish guidance related to the claim review process. This will allow review to be performed prior to payer adjudication system acquisition.

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