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Other Health Care Benefit Management

Our other health care benefit management enhances the value of your plan by helping your employees manage costs for services not covered by their provincial plan, including:

  • vision care
  • paramedical
  • hospital
  • medical supplies and equipment 

Our leading edge, online processing technologies verify claim accuracy and benefits in real time. Within seconds, claims are processed to confirm a member’s coverage eligibility and payment information. Express Scripts Canada’s responsive systems allow our clients’ designated users to construct adjudication rules, limits, conditions and process flows. 

The key features of ESC’s Other Health Claims adjudication system include:

  • Ability to differentiate between private and provincial co-ordination of benefits (COB)
  • Rules for provincial COB services/products
  • Letter generation
  • Ability to set COB rules at the group/subgroup, client and patient levels
  • Reasonable and customary pricing

Claims are adjudicated in Canadian dollars, according to program benefit rules in effect at the time services were provided or products were purchased. In addition, the system supports the reversal and resubmission of claim information, ensuring that the verification parameters in effect at the time the service or purchase occurred can be applied. This includes claim history and frequency history counters, as well as the claimed-against portion of the predeterminations for other health care benefits. The system can be customized so that edits are bypassed based on policy rules, which includes messages and frequency limitations.

Doctor pointing at an x-ray while looking at other physicians, Express Scripts Canada
Express Scripts Canada