SAMPLE. Dental Claim Form. X Patient/Guardian Signature. X Subscriber Signature. X Signed (Treating Dentist) 54. NPI 55.

Transcription

1 HEADER INFORMATION 1. Type of Transaction (Mark all applicable boxes) Dental Claim Form fold fold Statement of Actual Services EPSDT / Title XIX 2. Predetermination/Preauthorization Number RECORD OF SERVICES PROVIDED 24. Procedure Date (MM/DD/CCYY) 25. Area 26. of Oral Tooth Cavity System 27. Tooth Number(s) or Letter(s) 28. Tooth Surface 29. Procedure Code 29a. Diag. Pointer 29b. Qty. 30. Description 31. Fee Missing Teeth Information (Place an X on each missing tooth.) 34. Diagnosis Code List Qualifier ( ICD-9 = B; ICD-10 = AB ) 31a. Other a. Diagnosis Code(s) A C Fee(s) (Primary diagnosis in A ) B D 32. Total Fee 35. Remarks AUTHORIZATIONS 36. I have been informed of the treatment plan and associated fees. I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan, unless prohibited by law, or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted by law, I consent to your use and disclosure of my protected health information to carry out payment activities in connection with this claim. X Patient/Guardian Signature Date Ancillary claim/treatment information 38. Place of Treatment n (e.g. 11=office; 22=O/P Hospital) (Use Place of Service Codes for Professional Claims ) 40. Is Treatment for Orthodontics? No (Skip 41-42) Yes (Complete 41-42) 42. Months of Treatment 43. Replacement of Prosthesis No Yes (Complete 44) 39. Enclosures (Y or N) 41. Date Appliance Placed (MM/DD/CCYY) SAMPLE 37. I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to the below named dentist or dental entity. X Subscriber Signature Date Billing Dentist or Dental Entity (Leave blank if dentist or dental entity is not submitting claim on behalf of the patient or insured/subscriber.) 48. Name, Address, City, State, Zip Code Request for Predetermination/Preauthorization Insurance Company/Dental Benefit Plan Information 3. Company/Plan Name, Address, City, State, Zip Code other coverage (Mark applicable box and complete items If none, leave blank.) 4. Dental? Medical? (If both, complete 5-11 for dental only.) 5. Name of Policyholder/Subscriber in # 4 (Last, First, Middle Initial, Suffix) 6. Date of Birth (MM/DD/CCYY) 7. Gender 49. NPI 50. License Number 51. SSN or TIN M F 8. Policyholder/Subscriber ID (SSN or ID#) 9. Plan/Group Number 10. Patient s Relationship to Person named in #5 Self Spouse Dependent Other 11. Other Insurance Company/Dental Benefit Plan Name, Address, City, State, Zip Code POLICYHOLDER/SUBSCRIBER INFORMATION (For Insurance Company Named in #3) 12. Policyholder/Subscriber Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code 13. Date of Birth (MM/DD/CCYY) 14. Gender 16. Plan/Group Number 17. Employer Name Patient InformATION 18. Relationship to Policyholder/Subscriber in #12 Above Self Spouse Dependent Child Other 20. Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code 21. Date of Birth (MM/DD/CCYY) 22. Gender M 44. Date of Prior Placement (MM/DD/CCYY) 45. Treatment Resulting from Occupational illness/injury Auto accident Other accident M 46. Date of Accident (MM/DD/CCYY) 47. Auto Accident State TREATING DENTIST AND TREATMENT LOCATION INFORMATION 53. I hereby certify that the procedures as indicated by date are in progress (for procedures that require multiple visits) or have been completed. X Signed (Treating Dentist) Date 54. NPI 55. License Number 56. Address, City, State, Zip Code 56a. Provider Specialty Code F F 15. Policyholder/Subscriber ID (SSN or ID#) 19. Reserved For Future Use 23. Patient ID/Account # (Assigned by Dentist) fold fold 52. Phone Number ( ) - 52a. Additional Provider ID 2012 American Dental Association J430D (Same as ADA Dental Claim Form J430, J431, J432, J433, J434) 57. Phone Number ( ) Additional Provider ID To reorder call or go online at adacatalog.org

2 The following information highlights certain form completion instructions. Comprehensive ADA Dental Claim Form completion instructions are printed in the CDT manual. Any updates to these instructions will be posted on the ADA s web site (ADA.org). GENERAL INSTRUCTIONS A. The form is designed so that the name and address (Item 3) of the third-party payer receiving the claim (insurance company/dental benefit plan) is visible in a standard #9 window envelope (window to the left). Please fold the form using the tick-marks printed in the margin. B. Complete all items unless noted otherwise on the form or in the CDT manual s instructions. C. Enter the full name of an individual or a full business name, address and zip code when a name and address field is required. D. All dates must include the four-digit year. E. If the number of procedures reported exceeds the number of lines available on one claim form, list the remaining procedures on a separate, fully completed claim form. COORDINATION OF BENEFITS (COB) When a claim is being submitted to the secondary payer, complete the entire form and attach the primary payer s Explanation of Benefits (EOB) showing the amount paid by the primary payer. You may also note the primary carrier paid amount in the Remarks field (Item 35). There are additional detailed completion instructions in the CDT manual. DIAGNOSIS CODING The form supports reporting up to four diagnosis codes per dental procedure. This information is required when the diagnosis may affect claim adjudication when specific dental procedures may minimize the risks associated with the connection between the patient s oral and systemic health conditions. Diagnosis codes are linked to procedures using the following fields: Item 29a Diagnosis Code Pointer ( A through D as applicable from Item 34a) Item 34 Diagnosis Code List Qualifier (B for ICD-9-CM; AB for ICD-10-CM) Item 34a Diagnosis Code(s) / A, B, C, D (up to four, with the primary adjacent to the letter A ) PLACE OF TREATMENT Enter the 2-digit Place of Service Code for Professional Claims, a HIPAA standard maintained by the Centers for Medicare and Medicaid Services. Frequently used codes are: 11 = Office; 12 = Home; 21 = Inpatient Hospital; 22 = Outpatient Hospital; 31 = Skilled Nursing Facility; 32 = Nursing Facility The full list is available online at PROVIDER SPECIALTY This code is entered in Item 56a and indicates the type of dental professional who delivered the treatment. The general code listed as Dentist may be used instead of any of the other codes. Category / Description Code Dentist A dentist is a person qualified by a doctorate in dental surgery (D.D.S.) or dental medicine (D.M.D.) licensed by the state to practice dentistry, and practicing within the scope of that license. General Practice Dental Specialty (see following list) Dental Public Health Endodontics Orthodontics Pediatric Dentistry Periodontics Prosthodontics Oral & Maxillofacial Pathology Oral & Maxillofacial Radiology Oral & Maxillofacial Surgery Code X SAMPLE 1223G0001X Various 1223D0001X 1223E0200X 1223X0400X 1223P0221X 1223P0300X 1223P0700X 1223P0106X 1223D0008X 1223S0112X Provider taxonomy codes listed above are a subset of the full code set that is posted at

3 ADA Dental Claim Form Instructions Providers must use the 2012 ADA Dental Claim Form when requesting payment for dental services provided under the Kansas Medical Assistance Program (KMAP). Claims can be submitted on the KMAP secure website, as an electronic 837 file, through Provider Electronic Solutions (PES), or on an ADA Dental paper claim form. When a paper claim is submitted for a KMAP beneficiary, KMAP must be indicated on the form and the form should be completed using the instructions indicated below. Claims not meeting these submission requirements will be returned to the provider. KanCare (managed care) claims should be submitted to the appropriate KanCare managed care organization (MCO). Field 1 Field 2 Field 3 Field 4 Field 5 Field 6 Field 7 Field 8 Field 9 Field 10 Field 11 Field 12 Field 13 Field 14 Field 15 Field 16 Field 17 Field 18 Type of Transaction Select most applicable box for claim. Predetermination/Preauthorization Number Not required. Name, Address, City, State, ZIP Code Enter the primary insurance address. If the primary payer is KMAP, enter the KMAP mailing address. Other Dental or Medical Coverage? Select box(es) if applicable for claim. Other Insured s Name (Last, First, Middle Initial, Suffix) Enter the primary insurance policy holder s name. If the policy holder is the beneficiary, enter the beneficiary s name. Date of Birth (MM/DD/CCYY) Enter the primary insurance policy holder s date of birth (DOB). If the policy holder is the beneficiary, enter the beneficiary s DOB. Gender Select the applicable box for the policy holder. Subscriber Identifier (SSN or ID#) Enter the primary insurance policy holder s identification (ID) number. Plan/Group Number Enter the primary insurance policy holder s plan or group number. Patient s Relationship to Other Insured (Check applicable box) Select the most applicable box. Other Carrier Name, Address, City, State, ZIP Code If applicable, enter a secondary insurance address. Name (Last, First, Middle Initial, Suffix), Address, City, State, ZIP Code Enter the beneficiary s name and address. Date of Birth (MM/DD/CCYY) Enter the beneficiary s DOB. Gender Select the applicable policyholder s gender. Subscriber Identifier (SSN or ID#) Enter the beneficiary s 11-digit KMAP ID number. Plan/Group Number Not required. Employer Name Not required. Relationship to Primary Insured (Check applicable box) Select self.

4 Field 19 Field 20 Field 21 Field 22 Field 23 Field 24 Field 25 Field 26 Field 27 Field 28 Field 29 Reserved for future use. Name (Last, First, Middle Initial, Suffix), Address, City, State, ZIP Code Enter the beneficiary s name and address. Date of Birth (MM/DD/CCYY) Enter the beneficiary s DOB. Gender Select the patient s applicable gender. Patient ID/Account# (Assigned by Dentist) Not required. Procedure Date (MM/DD/CCYY) Enter the date of service. Area of Oral Cavity Enter the area of the oral cavity: 00 (EOC), 01 (UA), 02 (LA), 10 (UR), 20 (UL), 30 (LL), 40 (LR). Tooth System Not required. Tooth Number(s) or Letter(s) Enter the tooth number or letter of detailed service. Tooth Surface Enter the tooth surface of the detailed service. Procedure Code Enter the five-digit dental procedure code. Field 29a Diagnosis Code Pointer Enter the letter(s) from Item 34 that identify the diagnosis code(s) applicable to the dental procedure. List the primary diagnosis pointer first. Field 29b Quantity Enter the number of times (01-99) the procedure identified in Item 29 is delivered to the patient on the date of service shown in Item 24. The default values is 01. Field 30 Field 31 Description Enter the detailed service description. Fee Enter the detailed service fee. Field 31a Other Fee(s) When other charges applicable to dental services provided must be reported, enter the amount here. Charges may include state tax and other charges imposed by regulatory bodies. Field 32 Field 33 Field 34 Total Fee Enter the total of charges for all services, not including any amount listed in Field 31a. If it is a multipage claim, only list the total of all services on the last page of the claim. Missing Teeth Information Not required. Diagnosis Code List Qualifier Enter the appropriate code to identify the diagnosis code source: B = ICD-9-CM; AB = ICD-10-CM (as of October 1, 2015). Note: Only required when the diagnosis may have an impact on the adjudication of the claim. Field 34a Diagnosis Code(s) Enter up to four applicable diagnosis codes after each letter (A-D). The primary diagnosis code is entered adjacent to the letter A. Note: Only required when the diagnosis may have an impact on the adjudication of the claim. Field 35 Remark Enter any remarks. This field can be used to list an original internal control number (ICN) for timely filing purposes. It can also be used to convey additional information you believe is necessary for the payer to process the claim. For example, on a secondary claim, you can enter the amount the primary carrier paid.

5 Field 36 Field 37 Patient/Guardian signature Date Obtain signature from the beneficiary or beneficiary s guardian. Subscriber signature Date Obtain signature from the beneficiary or beneficiary s guardian. Field 38 Field 39 Field 40 Field 41 Field 42 Field 43 Field 44 Field 45 Field 46 Field 47 Field 48 Field 49 Field 50 Field 51 Field 52 Place of Treatment Enter the 2-digit place of service (POS) code for professional claims, a HIPAA standard. Frequently used codes include: 11 = Office 12 = Home 19 = Off campus outpatient hospital 21 = Inpatient hospital 22 = On campus outpatient hospital 31 = Skilled nursing facility 32 = Nursing facility Number of Enclosures (00-99) Enter a Y or N to indicate whether or not there are enclosures of any type included with the claim submission (such as radiographs, oral images, models). Is Treatment for Orthodontics? Not required. Date Appliance Placed (MM/DD/CCYY) Not required. Months of Treatment Remaining Not required. Replacement of Prosthesis? Not required. Date Prior Placement (MM/DD/CCYY) Not required. Treatment Resulting from (Check applicable box) Not required. Date of Accident (MM/DD/CCYY) Enter the date of the accident. Auto Accident State Enter the state in which the accident occurred. Name, Address, City, State, ZIP Code Enter the billing dentist s physical address. Enter the performing dentist s National Provider Identifier (NPI) number. License Number Not required. SSN or TIN Not required. Phone Number Not required. Field 52A Provider ID Enter the billing dentist s KMAP 9-digit number and alpha location code. Field 53 Field 54 Field 55 Field 56 Signed (Treating Dentist) Date Obtain the dentist s signature and date of signature. Enter the performing dentist s NPI number. License Number Not required. Address, City, State, ZIP Code Enter the performing dentist s physical address. Field 56A Provider Specialty Code Not required.

6 Field 57 Field 58 Phone Number Not required. Provider ID Enter the billing dentist s KMAP 9-digit number and alpha location code.