Introduction

Tuuthfairy makes retrieving patient dental insurance data easier than ever with a new kind of dental insurance API. Alongside traditional EDI-based insurance data, Tuuthfairy turns provider insurance portals into accessible APIs to combine with EDI data, maximizing data flexibility, fidelity, and interoperability.

Looking to verify patient dental insurances?

By default, Tuuthfairy offers a simplified version of the standard 270/271 Eligibility Benefit Inquiry and Response (simple in usage, not in comprehensiveness!) After millions of eligibility and benefits requests, our data team has built an inference layer that maps payer specific language to normalized values and data types, expanding data values beyond their string based representations and extrapolating category-level data to their inferred procedures. For a majority of payers, EDI-based data alone will answer basic eligibility questions and allow you to verify patients’ dental insurances:

1. Is the patient's insurance active?
2. What are the patient's maximum and deductible limits?

EDI data will sometimes provide partial answers on co-insurances, limitations, and history.

Verifying eligibility and benefits is harder than it seems.

Insurances define benefits with the following properties:

1. Co-insurance: What % of the total cost is covered by insurances?
2. Maximum: Maximum amount insurances will cover for the year.
3. Deductible: Dollar amount patients must pay first for covered services before insurances’ coverage kicks in.
4. Frequency Limitation: Restriction set by insurance for the maximum number of services covered in a certain period of time.
5. History: History of usage for a specific benefit, used in conjunction with Frequency Limitation to determine coverage.
6. Age Limitation: Age restriction set by insurance for availability of coverage.
7. Missing Tooth Clause: Whether or not dental insurance will cover the costs of replacing the tooth if the tooth fell out or was extracted before the current dental coverage started.
8. Waiting Period: Length of time until full dental benefits begins.
9. Downgrades: When insurance companies elect to pay for the least expensive procedure if there is more than one acceptable option.

In reality most of these fields are not defined in most EDI-based responses. (our research shows that, less than 20% of the above datasets are defined across all major properties and payers). To “automate” eligibility and benefits, you have to stitch together many solutions, for instance:

1. connect with EDI-based systems,
2. retrieve data from insurance provider portals,
3. manage website logins, phone calls, unresponsive systems, non-interoperable data and much more.

Tuuthfairy allows you to connect and manage insurance web portals as first class datasources, turning insurance websites into APIs and consolidating data gathering and normalization workloads. With Tuuthfairy, you can start basic with EDI-based data, and graduate to more advanced datasets as use cases and product fidelity requirements increase.