Medigent® Claims and Payment Modules

Supporting the full scope of health care benefit programs

Streamline business processes to improve efficiency

Medigent® Claims Processing Solutions are founded on robust business rules specific to each jurisdiction. Users can configure the system with advanced rules development, which lessens the need for manual assessment of claims. Medigent's claims and payment modules can be used individually or in combination, so you can begin the modernization journey in any program area you wish.


With the Medigent Medical module, you can:

  • submit and adjudicate claims
  • capture rich data elements related to each claim
  • configure the life cycle of your claims to your specific requirements
  • customize adjudication rules and fee schedules
  • support a wide range of payment types, such as:
    • fee-for-service
    • sessional claims
    • capitation
    • salaried
  • integrate claims with payment systems

The Medical module supports both ICD9 and ICD10 diagnosis standards.

Pharmacy and Supplementary Benefits

The Medigent Pharmacy and Supplementary Benefits module is designed to automate and streamline the daily business processes required to manage a jurisdiction’s drug insurance programs.

This module is an integrated solution that:

  • Manages the end-to-end Prior Authorization workflow for those benefits that require pre-approval 
  • Supports CPhA 3.0 and NeCST messaging for online submission of pharmacy claims
  • Supports real-time claims by individual transaction, in batch via standard messaging, or through manual entry


With the Medigent Dental module, you can:

  • submit and adjudicate claims in real time and batch
  • layer business and financial rules
  • incorporate fee code structures with numerous properties such as
    • age restrictions
    • frequency limitations
    • fiscal elements
  • accept electronic submission of claims from dentist offices across Canada
  • run trial adjudications on each request to determine submission outcome

The Medigent Dental module is CDAnet compliant.

Medical Transportation

Pre-authorize and track the cost of client medical transportation:

  • Encapsulate travel expenses – from a patient's departure to return
  • Automate your information capture process with electronic loading from third-party systems
  • Track a range of transportation types, including scheduled air, ferries, medivac, and ambulance services
  • Link vendor invoices to pre-authorizations for record keeping, and to flag unauthorized travel
  • Record various transaction types including payments and credits
  • Integrate travel expenses with your financial systems

Reciprocal Billing

Within the Medical module, Medigent currently manages reciprocal billing for seven Canadian jurisdictions. It handles all claims adjudication and payment processes associated with the Medicare reciprocal program, where programs and adjudication rules vary according to the policies of each jurisdiction.

Medigent’s reciprocal billing capabilities allow you to manage the complete lifecycle of claims associated with inter-jurisdictional reciprocal agreements. Its main features include:

  • invoice management
  • claims activity processing (add, cancel, reverse)
  • management of adjustment requests and recoveries
  • payment processing

These capabilities support processing for the following claim types:

  • in-province provider for out-of-province beneficiary
  • in-province hospital for out-of-province beneficiary
  • out-of-province provider for in-province beneficiary
  • out of-province hospital for in-province beneficiary

These capabilities can also be leveraged for processing invoices associated with non-reciprocal reimbursements such as out-of-country claims from residents.