DENTAL CARE

Pay–Direct and Your Pay–Direct Number

Electronic submission of Dental Care expenses will be possible in many situations. Within one month of your enrollment into the Plan, you will receive a welcome letter that has your certificate and group number on it that you and your eligible dependants will use when claiming benefits at the dentist.

It is important that your dentist have this new information. Without it, they will not be able to process an eligible claim electronically.

Transmitting Claims Electronically

In most cases, your dental office will file claims electronically. AFBS works with ClaimSecure to provide members and their covered dependants with pay-direct claims payments for Dental Care coverage. Since these claims are processed through the ClaimSecure network, the dental office requires the information contained on your welcome letter in your insurance package to process your claim.

When Electronic Submission is Not Possible

Electronic submission is not possible for all dental claims. For example, dental claims for procedures, including certain x-rays and major restorative work, cannot be submitted electronically. Your dentist will let you know when a paper claim form must be completed.

If your dental office cannot submit your claim electronically, you must send AFBS an original standard dental claim form which must be completed by your dentist. The standard dental claim form is available from your dental office.

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Some Dental Expenses Require Pre-determination

If your dentist recommends dental work that will cost more than $500 or includes procedures such as crowns, bridgework, veneers, implants, onlays or inlays, you must have your expense pre-determined by AFBS. Your dentist must provide AFBS with specific information, including x-rays, study moulds or casts.

Pre-determination is not required if treatment is the result of an emergency. If the emergency treatment is for a crown or bridge, you must submit x-rays with your claim. Pre-determination is not necessary for a crown if a root canal has been performed on the tooth. The dentist needs to indicate this on the claim form.

Through the pre-determination process, you will have confirmation of the amount eligible for reimbursement through the Program before treatment starts.

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Second Payor Claims/ Explanation of Benefits (EOB)

If AFBS is the second payor, please include the receipt of claim settlement information, often called an Explanation of Benefits (EOB), from the other insurance company along with copies of the completed standard dental claim form to AFBS.

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Deadlines for Claims Submission

Claims for a previous Benefit Year must be submitted within 90 days of the close of the Benefit Year indicated on your Certificate of Insurance to remain eligible for payment. When coverage is terminated AFBS must receive your claim submissions within 30 days of your coverage termination.

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ClaimSecure

ClaimSecure provides many employee benefits administrative and claims adjudication services to insurance companies and employers. AFBS uses ClaimSecure's prescription drug and dental care claims adjudication systems in order to be able to provide online adjudication to the membership. However, with the exception of online adjudication (which is handled by a computer) all claims are adjudicated by AFBS staff. Because AFBS uses the ClaimSecure computer platform, any prescription drug or dental reimbursement cheques are issued by their system even when the claim has been adjudicated by AFBS staff.

AFBS wants to provide your reimbursement to you as quickly as possible. Online adjudication reimbursement cheques are processed the next day. Delays in processing are prevented when claim forms are sent to directly to AFBS. Never contact or send claims to ClaimSecure.

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