Dental Claims

Completing New Dental Claims

Dental Header 1
Field	Description
Program	Select the Medicaid program.
Claim Frequency	Select "1" to submit an original claim.
Provider ID	Select the eight-digit Medicaid billing provider number.
Client ID	Select the 10-digit recipient identification number.
Release of Medical Data	This field defaults to "Y." Select "N" only to indicate that the provider does not have a signed statement on file authorizing the release of medical data to other organizations.

Select the Header 2 tab. Enter data into all of the required boxes on Header 2 using the following table as a guide.

Tip Prior authorization (PA) numbers and Place of Service (POS) codes entered on Header 2 will apply to all lines on the claim unless overridden by PA numbers and POS codes entered on the Service 1 tab.

Dental Header 2
Field	Description
Place of Service	Enter or select the two-digit place of service code. The same place of service code cannot be entered both here and on the Service 1 screen.
Prior Authorization	Enter the seven-digit prior authorization (PA) number (if applicable). The same PA cannot be entered both here and on the Service 1 screen.
Emergency Ind	Select "Y" if the service was emergency related. If "Y" is selected, bill nonemergency services on a separate claim. This box defaults to "N."
Total Months	Enter the total number of months of orthodontic treatment (if applicable). This box is required for orthodontic services only.
Months Remaining	Enter the number of treatment months remaining for a transfer patient (if applicable). This box applies to orthodontics only.
Rendering Provider ID	Select the eight-digit rendering (performing) provider number, if different from the billing provider.
Other Insurance Ind	Select "Y" if the client has other insurance coverage for dental services.

If you do not have other insurance information to enter, proceed to step 9. If you have other insurance information to enter, select the OI tab. Enter data into all of the required fields on the OI tab using the following table as a guide. Refer to the Other Insurance Medicare Chapter of this manual for more information.

Tip You may report other insurance payments or adjustments on the OI Adjustment tab (header level) in PES.

Dental OI
Field	Description
Release of Medical Data	Select "Y" or "N" to indicate whether the provider has a signed statement on file authorizing the release of medical data to other organizations. The information entered in this box has no impact on the outcome of your claim.
Benefits Assignment	Select "N" only to indicate that the client, or authorized person, did not authorize benefits to be assigned to the provider. This box defaults to "Y." The information entered in this box has no impact on the outcome of your claim.
Claim Filing Ind Code	Select the type of other insurance claim being submitted.
Carrier Code	Select the policyholder’s carrier code. Then press Save to populate the Policyholder Last Name and First Name boxes.

7. Select the OI Adj tab.
8. Enter data into all the required boxes on the OI Adj tab using the following table as a guide.

Tip When there are multiple payers for a single client, complete all information for each payer prior to beginning a new payer.

Tip An area of the oral cavity can represent a specific quadrant or sextant, the maxillary or mandibular area, or the entire oral cavity.

Dental OI Adjustment
Field	Description
Paid Date/Amount	Enter the date the other insurance paid the claim using the MM/DD/CCYY format and the total amount paid by the other insurance. This field is required if it is not entered on the service adjustment tab.
Allowed Amount	Enter the amount allowed by other insurance, if applicable.
Adjustment Group Cd	Select the code identifying the general category of payment adjustment by the other insurance, if applicable. Enter "PR" if insurance deductible, coinsurance, or co-pay has been indicated on the insurance claim or remittance advice. If you enter an adjustment group code, you must also enter at least one adjustment reason code. You may enter up to six adjustment reason codes per adjustment group code. This box is only required if an insurance carrier did not pay the claim in full.
Reason Codes/Amts	Select the code identifying the reason for the adjustment—the difference between the billed and paid amounts—given by the other insurance. Enter the amount indicated by the other insurance for each reason code. This box is only required if an insurance carrier did not pay the claim in full.

Select the Service 1 tab. Enter data into all the required boxes on the Service 1 tab using the following table as a guide.

Tip The maximum number of details that can be submitted per form is 50.

Dental Service 1
Field	Description
Date of Service	Enter the date of service using the MM/DD/CCYY format.
Place of Service	Enter or select the two-digit place of service (POS) code here, only if it is different from the POS indicated on the Header 2 tab.
Procedure	Enter or select the Current Dental Terminology (CDT) procedure code.
Modifiers	Enter or select the two-digit modifier(s), if applicable.
Tooth	Enter the tooth number, if applicable.
Surfaces	Select the surface(s), if applicable.
Oral Cavity Designation	Select the area(s), if applicable. The areas of the oral cavity are designated by a two-digit code; where at least one digit is zero, the valid values for these areas can be found in the Current Dental Terminology–4 (CDT-4) book.
Placement Indicator	Select the placement indicator, if applicable. If the placement indicator is "R," the placement date must be completed using the MM/DD/CCYY format. This field is for use with prosthodontics only.
Prior Authorization	Enter the seven-digit prior authorization number (if applicable). The same PA cannot be entered both here and on the Header 2 screen.
Units	Enter the number of units performed for the service billed. Example: 1.00 = 1 unit.
Billed Amount	Enter the total charges for the services rendered.

Select the Service 2 tab. Enter data into all the required boxes on the Service 2 tab using the following table as a guide. Click Save, then Close. Proceed to Submitting New Dental Claims.

Tip Refer to the Basic Skills chapter of this manual for information on screen-specific command buttons, such as Add Srv and Copy OI.

Next — Correcting Errors on Dental Claims
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