4.0 Dental Claim Form Instructions - Mississippi

[Pages:11]Mississippi Medicaid Provider Billing Handbook

Section: ADA Dental Claim Form Instructions

4.0 Dental Claim Form Instructions

This section explains the procedures for obtaining reimbursement for dental services submitted to Medicaid. Mississippi Medicaid accepts both electronic and paper dental claims. Dentists are strongly encouraged to bill electronic claims to reduce the potential for error and speed reimbursement. This section only addresses billing procedures and must be used in conjunction with the Administrative Code Title 23 Part 204. The Dental Fee Schedule is available on the Medicaid web site at or on the Web Portal at https:/ / msenvision/ index.do. If you have questions, please contact the fiscal agent's Provider and Beneficiary Services Call Center toll-free at 1-800-884-3222.

Provider Types

The follow ing provider types should bill using the Dental claim form :

Dentists Federally Qualified Health Centers (FQHC) dentists Rural Health Clinic (RHC) dentists

Before You Bill Medicaid

Check the beneficiary's eligibility for Med icaid . Check the beneficiary's eligibility for d ental services. Check the beneficiary's service lim its. Check the proced ure code on the d ental fee schedule to d eterm ine if prior authorization is

n eed ed . Check for other d ental insurance coverage. Check the proced ure code on the fee sched ule to see if Mississippi Med icaid covers that cod e. Check the current version of the ADA's Current Dental Terminology code boo k for correct

proced ure cod es. Check to see if the proced ure cod e requires tooth, surface, or quad rant indicators. Check to see if co-payment is required .

Current Dental Terminology (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright ? 2008 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

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Electronic D ental Claims

Mississippi Medicaid Provider Billing Handbook

Electronic d ental claims m ay be subm itted to Mississippi Med icaid by these m ethod s: Using the Web Portal Claim s Entry feature Using WINASAP (free softw are available from the fiscal agent) Using other proprietary softw are purchased by the d ental provid er. Electronic d ental claims m ust be subm itted in a form at that is H IPAA com pliant w ith the AN SI X12 Dental claim stand ard .

Paper Dental Claims

Claim s should be com pleted accurately to ensure proper claim adjud ication. Rem em ber the follow ing:

Com plete an original ADA American Dental Association Dental Claim form . Mississippi Med icaid w ill only accept the ADA Am erican Dental Association Dental Claim form ; no other versions w ill be accepted.

N o photocopied claim s w ill be accepted . Use blue or black type or ink. Be sure the inform ation on the form is legible. Do not use highlighters. Do not use correction fluid or correction tape. Ensure that names, cod es, num bers, etc., print in the d esignated field s for proper alignm ent. Claim m ust be signed . Rubber signature stam ps are acceptable.

Multi-Page Paper Claims

When subm itting ADA Am erican Dental Association Dental claim s form w ith m ultiple pages, please follow these guid elines:

If the num ber of proced ures reported exceed s the num ber of lines available on one claim (10 lines per claim ), the rem aining proced ures m ust be listed on a separate, fully com pleted claim form .

Do not total the first form. Staple or clip the 2 pages together. If reporting TPL paym ent, indicate in field #35 on the first claim. Only one copy of an attachm ent (e.g. EOB, EOMB, Consent Form ) is required .

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Mississippi Medicaid Provider Billing Handbook

Paper Claims w ith Attachments

When subm itting attachm ents w ith the ADA American Dental Association Dental claim form , please follow these guid elines:

Do not staple attachm ents m ore than once. Any attachm ent should be m arked w ith the beneficiary's nam e and Medicaid ID num ber. For d ifferent claim s that refer to the sam e attachm ent, a copy of the attachm ent m ust

accom pany each claim . Billing Tip

Be sure to include Treatment Authorization N umber (TAN ), timely filing Transaction Control N umber (TCN ), proper procedure codes, modifiers, units, etc. to prevent your claim from denying inappropriately. Claim Mailing Address Once the claim form has been com pleted and checked for accuracy, please m ail the com pleted claim form to:

Mississippi Medicaid Program P. O. Box 23076

Jackson, MS 39225-3076

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Mississippi Medicaid Provider Billing Handbook

ADA American Dental Association Dental Claim Form

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Mississippi Medicaid Provider Billing Handbook

ADA American Dental Association Dental Claim Form Instructions for Mississippi Medicaid

Field Requirement

Field Name and Instructions for ADA Dental Claim Form

1

N ot Required Type of Transaction: N ot Required .

Predetermination/Preauthorization N umber: Enter TAN num ber for

2

Required if Applicable

services that require PA and approval by the UM/ QIO. Refer to the Ad m inistrative Code and Dental Fee Sched ule at http:/ / w w w .m ed icaid .m for specific instructions about services that

require PA.

Company/Plan N ame, Address, City, State, and Zip Code: Enter the nam e

and ad d ress for the insurance com pany that is the third party payer receiving

3

Required

the claim . For Mississippi Med icaid , enter Mississippi Med icaid Program , P. O. Box 23076, Rid geland , MS 39225-3076. If the beneficiary has m ore than

one d ental insurance plan and Med icaid is the second ary payer, enter the

Med icaid ad d ress in this field and com plete field s 4 through 11 and field 17.

Other D ental or Medical Coverage? Check "N O" if the patient d oes not

4

Required

have d ental coverage und er any other d ental or m ed ical benefit plan and d o not com p lete field s 5-11. Check "YES" if the patient has d ental coverage

und er any other d ental or m ed ical plan.

N ame of Policyholder/Subscriber w ith Other Coverage Indicated in #4

5

Required if Applicable

(Last, First, Middle Initial, Suffix): If "yes" is checked in field #4, enter the nam e of the policyhold er for the other d ental or m ed ical plan. If the patient has other coverage through a spouse, d om estic partner or, if a child , through

a parent, the nam e of the person w ho has other coverage is reported here.

6

Required if Applicable

D ate of Birth (MM/D D /CCYY): If "yes" is checked in field #4, enter the d ate of birth of the person listed in field #5. The d ate m ust be entered w ith tw o d igits for the month and d ay, and four d igits for the year of birth .

7

Required if Gender: If "yes" is checked in field #4, mark the gend er of the person w ho is Applicable listed in field #5. Mark "M" for male or "F" for female as ap p licable.

Policyholder/Subscriber Identifier (SSN or ID #): If "yes" is checked in field

8

Required if #4, enter the Social Security N um ber or the id entifier for the person listed in Applicable field #5. The id entifier num ber is a num ber assigned by the payer/ insurance

com pany to this ind ividual.

9

Required if Plan/Group N umber: If "yes" is checked in field #4, enter the group plan or Applicable policy num ber for the person id entified in field #5.

10

Required if Applicable

Patient's Relationship to Person N amed in Field #5: If "yes" is checked in field #4, check the box correspond ing to the patient's relationship to the other insured nam ed in field #5.

11

Required if Applicable

Other Insurance Company/D ental Benefit Plan N ame, Address, City, State, Zip Code: If "yes" is checked in field #4, enter the com plete inform ation of the ad d itional payer, benefit plan or entity for the insured nam ed in field #5.

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Mississippi Medicaid Provider Billing Handbook

Field Requirement

Field Name and Instructions for ADA Dental Claim Form

Policyholder/Subscriber N ame (Last, First, Middle Initial, Suffix), Address,

12

Required City, State, and Zip Code: Enter the com plete nam e, ad d ress and zip cod e of

the Medicaid beneficiary receiving treatm ent.

13

Required

D ate of Birth (MM/D D /CCYY): Enter the Med icaid beneficiary's d ate of birth w ith tw o d igits for the m onth and d ay and four d igits for the year.

Gender: Mark "M" for male or "F" for female as applicable for the

14

Required

beneficiary's gend er.

Policyholder/Subscriber Identifier (SSN or ID #): Enter the full 9-digit

15

Required Med icaid ID num ber for the beneficiary as indicated on the beneficiary's

Med icaid ID card .

16 N ot Required Plan/ Group N um ber: N ot required .

Employer N ame: Required if the beneficiary has other d ental insurance in

17

Required if Applicable

ad d ition to Med icaid . Enter the nam e of the policyhold er/ subscriber's em p loyer.

Relationship to Policyholder/Subscriber in #12 Above: Mark the

18

Required

relationship of the patient to the person id entified in field #12 w ho has the prim ary insurance coverage. For Med icaid beneficiaries, m ark the box titled

"Self" and skip to field #24.

19 N ot Required Stud ent Status: N ot required . N am e (Last, First, Mid d le Initial, Suffix), Ad d ress, City, State, and Zip Cod e:

20 N ot Required N ot required .

21 N ot Required Date of Birth (MM/ DD/ CCYY): N ot required .

22 N ot Required Gend er: N ot required .

23 N ot Required Patient ID/ Account# (Assigned by Dentist): N ot required .

Procedure D ate (MM/D D /CCYY): Enter the proced ure d ate for actual

24

Required services perform ed . The d ate m ust have tw o d igits for the m onth, tw o for the

d ay, and four for the year.

Area of Oral Cavity: Enter the area of the oral cavity designated by a tw o-

d igit cod e as follow s:

25

Required if Applicable

00 Entire oral cavity 01 Maxillary arch

02 Mandibular arch

26 N ot Required Tooth System : N ot required .

10 Upper right quad rant 20 Upper left quad rant 30 Low er left quad rant 40 Low er right quad rant

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Mississippi Medicaid Provider Billing Handbook

Field Requirement

Field Name and Instructions for ADA Dental Claim Form

Tooth N umber(s) or Letter(s): Enter the appropriate tooth num ber or letter w hen the proced ure directly involves a tooth or range of teeth. Otherw ise, leave blank.

If the sam e proced ure is perform ed on m ore than a single tooth on the sam e d ate of service, report each proced ure cod e and tooth involved on separate lines on the claim form .

27

Required if When a proced ure involves a range of teeth, the range is reported in this Applicable field . This is d one either w ith a hyphen " -"to separate the first and last tooth

in the range (e.g., 1-4; 7-10; 22-27), or by the use of com m as to separate

ind ivid u al tooth num bers or ranges (e.g., 1, 2, 4, 7-10, 3-5, 22-27).

Supernum erary teeth in the perm anent d entition are id entified by tooth

num bers 51 through 82; for prim ary d entition, supernum erary is id entified

by placem ent of the letter "S" follow ing the letter id entifying the adjacent

prim ary tooth. See Figure 4-2 for a list of procedure cod es that require either

a tooth num ber or a quad rant cod e.

Tooth Surface: Enter a tooth surface cod e w hen the proced ure perform ed by

28

Required if tooth involves one or m ore tooth surfaces. See Figure 4-2 for a list of Applicable proced ure cod es that require a surface cod e.

Procedure Code: Enter the appropriate proced ure cod e from the current

29

Required

version of the Am erican Dental Association (ADA) Current Dental Term inology Manual.

29a

Required D iag Pointer: ("A" through "D ": as applicale from Item 34a)

29b N ot Required Qty

D escription: Enter a brief d escription of the service provid ed (e.g.,

30

Required abbreviation of the proced ure cod e's nom enclature).

Fee: Report the d entist's full fee or usual and custom ary charge. Do not

31

Required d ed uct co-paym ent from your usual and custom ary charge.

31a N ot Required Other Fee(s): N ot required

32

Required Total Fee: Enter the su m of all fees from lines in field #31.

33

Required if Applicable

Missing Teeth Information: Report a m issing tooth/ teeth w hen pertinent to period ontal, prosthod ontic (fixed and rem ovable), or im plant proced ures.

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Mississippi Medicaid Provider Billing Handbook

Field Requirement

Field Name and Instructions for ADA Dental Claim Form

34

Required Diagnosis Cod e List Qu alifier: (B for ICD-9-CM; AB for ICD-10-CM)

34a

Required

Diagnosis Cod e(s)/ A, B, C, D (up to four, w ith the prim ary ad jacent to the letter "A")

Remarks: If subm itting a claim that w as originally subm itted w ithin tw elve

(12) m onths from the d ate of service, but is now ov er tw elve (12) m onths old ,

35

Required if enter the 17-digit transaction control num ber (TCN ). If the beneficiary has Applicable d ental insurance other than Med icaid , and Med icaid is the second ary payer,

enter the payment am ount received from the prim ary d ental insurance in this

field .

Patient Consent: The beneficiary m ust sign his/ her name ind icating he/ she

has agreed that he/ she has been inform ed of the treatm ent plan, the costs of

treatm ent and the release of any inform ation necessary to carry out payment

activities related to the claim . If the beneficiary cannot w rite his/ her nam e,

he/ she should sign by a mark and have a witness sign his/ her name and

ind icate by w hom the nam e w as entered . If the beneficiary is a m inor or is

otherw ise unable to sign, any responsible p erson such as a parent or

guard ian m ust enter the beneficiary's nam e and w rite "By," sign his/ her

ow n nam e in the space, show his/ her relationship to the beneficiary, and

36

Required explain briefly w hy the beneficiary cannot sign. In lieu of having the

beneficiary sign a claim form on each visit, the provid er m ay retain a copy of

a statem ent of release signed by the beneficiary or his/ her guardian.

Med icaid w ill allow a beneficiary signature for a lifetim e w hen the provid er

has a signature authorization on file. On th e claim form , the provid er w ould

enter "Signature on file" to satisfy the signature guid elines. If the beneficiary

is unable to sign, the billing clerk m ay sign the beneficiary's nam e and

ind icate "By: (nam e of office person signing)." In ad dition, the rea son the

beneficiary is not available m ust be specified .

37 N ot Required Insured 's Signature: N ot required . Place of Treatment: Check the appropriate box to ind icate the place w here services w ere provid ed .

38

Required

Provider's Office Service provid ed in the d entist office

Hospital

Service provid ed in the inpatient or outpatient hospital

ECF

Service provid ed in an extend ed care facility, e.g.,

nursing hom e, PRTF, ICF/ MR

Other

Service provid ed in a location other than those listed .

39 N ot Required N um ber of Enclosures (00 to 99): N ot required .

40 N ot Required Is Treatm ent for Orthod ontics? N ot required .

41 N ot required Date Appliance Placed (MM/ DD/ CCYY): N ot required .

42 N ot Required Months of Treatm ent Rem aining: N ot required .

43 N ot Required Replacem ent of Prosthesis? N ot required .

44 N ot Required Date of Prior Placem ent (MM/ DD/ CCYY): N ot required .

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