Abbreviations CPT. General Enrollment Period Geographic practice cost index. Coordination of benefits

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1 Abbreviations A ABN ADA AFDC AHA AHIMA AHFS AMA APC ASC B BC BCAC BCBS BCBSA BRAC BS BSR C Ca CAT CCI CCS CF CHAMPVA CIM CLIA CMP CMS CMS-1500 CMS-1450 COB Advance Beneficiary Notice American Disabilities Act Aid to Families with Dependent Children American Hospital Association American Health Information Management Association American Hospital Formulary Service American Medical Association Ambulatory payment classification Ambulatory Surgical Center Blue Cross Beneficiary Counseling and Assistance Coordinator Blue Cross/Blue Shield Blue Cross and Blue Shield Association Base Realignment and Closure Blue Shield Beneficiary Services Representative Cancer or carcinoma Computerized axial tomography Correct Coding Initiative Certified Coding Specialist Conversion factor Civilian Health and Medical Program of Veterans Affairs Coverage Issues Manual Clinical Laboratory Improvement Act Competitive medical plan Centers for Medicare and Medicaid Services Insurance claim, developed by the National Uniform Claims Committee (NUCC), for use by noninstitutional providers and suppliers to bill third-party payers also known as the UB-92; insurance claim, developed by the National Uniform Billing Committee (NUBC), for use by institutional and other selected providers to bill thirdparty payers Coordination of benefits COBRA CPC CPT CRI CT D DEERS DME DMEPOS DMERC DoD DRG E EDI EGHP E/M EMC EOB EPO EPSDT ERISA ESRD F FECA FEHBP FELA FEP FI FMAP FPL FR G GEP GPCI Consolidated Omnibus Budget Reconciliation Act of 1985 Certified professional coder Current Procedural Terminology CHAMPUS Reform Initiative Computed tomography Defense Enrollment Eligibility Reporting System Durable medical equipment Durable Medical Equipment, Prosthetic and Orthotic Supplies Durable Medical Equipment Regional Carriers Department of Defense Diagnosis Related Groups Electronic data interchange Employer Group Health Plan Evaluation and Management Electronic media claim Explanation of benefits Exclusive provider organization Early and Periodic Screening, Diagnoses, and Treatment Employee Retirement Income Security Act of 1974 End-stage renal disease Federal Employment Compensation Act Federal Employee Health Benefits Program Federal Employment Liability Act Federal Employee Program Fiscal intermediary Federal Medical Assistance Percentage Federal poverty level Federal Register General Enrollment Period Geographic practice cost index

2 GPWW GRP# H HA HCF HCFA HCPCS HEDIS HIPAA Group practice without walls Group practice identification number Health Affairs Health Care Finder Health Care Financing Administration Healthcare Common Procedure Coding System Health Plan Employer Data and Information Set Health Insurance Portability and Accountability Act of 1996 Health Maintenance Organization Health Maintenance Organization HMO HMO Act of 1973 Assistance Act of 1973 HPSA Health Personnel Shortage Area I ICD ICD-9-CM IEP IPA IPA IPO J JCAHO L LA LC LHWCA International Classification of Diseases International Classification of Diseases 9th Revision Clinical Modification Initial Enrollment Period Individual practice association Independent practice association Integrated provider organization Joint Commission on Accreditation of Healthcare Organizations Lead Agent Limiting charge Longshore and Harbor Workers Compensation Act Limited license practitioners Local Medicare Carrier LLC LMC M MCM Medicare Carriers Manual MCO Managed Care Organization MFN Most favored nation MHSS Military Health Services System MM Major Medical MN Medically needy MRI Magnetic resonance imaging MSA Medical savings account MSDS Material Safety Data Sheet MSN Medicare Summary Notice MSO Management service organization MSP Medicare Supplemental Plan MTF Military treatment facility N NAS Nonavailability statement NCHS National Center for Health Statistics NCQA National Committee for Quality Assurance NEC Not elsewhere classifiable NMOP National Mail Order Pharmacy NonPAR Nonparticipating provider NP Nurse Practitioner NPI National Provider Identifier O OBRA Omnibus Budget Reconciliation Act of 1981 OCR Optical character reader OHI OMP OPAP ORIF OSHA P PA PAR PAYERID PCM PCP PFFS PFPWD PFS PIN PlanID PMO POS POS PPA PPN PPO PSO Q QDWI QI QMB R RBRVS RVU S SCHIP SLMB SOAP SSA SSI SSN SSO T TANF TEFRA TMA TOS TPA TPR TSC U UCR UPIN V VA Other health insurance Office of Personnel Management Outpatient Pretreatment Authorization Plan Open reduction with internal fixation Occupational Safety and Health Administration Physician Assistant Participating provider Payer identification number (now known as PlanID) Primary care manager Primary care provider Private fee-for-service plan Program for Persons with Disabilities Physician Fee Schedule Provider identification number National health plan identification number Program Management Organization Place of service Point-of-service plan Preferred provider arrangement Preferred provider network Preferred provider organization Provider-sponsored organization Qualified Disabled and Working Individual Qualifying Individual Qualified Medicare Beneficiary Resource-Based Relative Value Scale Relative value units State Children s Health Insurance Program Specified Low-income Medicare Beneficiary Subjective, Objective, Assessment, Plan Social Security Administration Supplemental Security Income Social Security Number Second surgical opinion Temporary Assistance for Needy Families Tax Equity and Fiscal Responsibility Act of 1982 TRICARE Management Activity Type of service Third-party administrator TRICARE Prime Remote TRICARE Service Center Usual, Customary, and Reasonable Unique Provider Identification Number Veterans Administration

3 Common Medical Terminology Prefixes, Suffixes, and Combining Forms a-, anababdominacrad- -ad adip- -al angiankylantiarthr- -asis, -esis, -iasis, -isis, -sis biblepharbrachybradybronchcardicephalcerviccolp-, kolpcontracranicrycyandacrydactyldedemiderm-, dermat- no; not away from abdomen extremities; top toward toward fat pertaining to vessel crooked; bent against joint condition two eyelid short slow bronchial tube heart head neck; cervix vagina against; opposite skull cold blue tear fingers; toes lack of; down half skin dextrdidis- -dynia dys- -ectomy -emesis -emia enend-, endoepierythr- -esis -esthesia etiexextrafibrforegalact-, lactgaster-, gastrgenitglossgluc-, glyc- -gram -graph -graphy gyn-, gyne-, gynechem-, hema-, hemathemihepathyp-, hyph- right two separation pain bad; painful excision; removal vomiting blood condition in; within in; within above; upon red condition nervous sensation cause out; away from outside fiber before milk stomach genitals tongue sugar, glucose record instrument for reading process of recording women; female blood half liver below; under

4 hyperhyster- -ia, -iasis -ic ileoilioininfrainterintra-, introipsi- -isis -itis juxtalarynglaterleuklingulip- -lith -lysis mal- -mania med-, medimega-, megalmelanmetametr-, metramonmusculo-, mymyelnasnecrneonephr-, nephranonnormoboculo-, optico-, opto- -oma omphalonychoo-, ovi-, ovooophor-, oophoron- -osis oste- -ostomosis, -ostomy, -stomosis, -stomy ot- -otomy -ous pach-, pachypanpara-, -para path-, -pathic, -pathy per- above; excessive uterus; womb condition pertaining to ileum (small intestine) ilium (hip bone) in; into; not within; into between within; into same condition inflammation near larynx (voice box) side white tongue fat; lipid stone breakdown bad obsessive preoccupation middle large black change; beyond uterus; measure one; single muscle spinal cord; bone marrow nose death new kidney not; no rule; order obstetrics eye tumor; mass umbilicus (navel) nail egg ovary condition usually abnormal bone new opening ear incision pertaining to heavy; thick all near; besides disease through peri- -pexy pharyngphleb- -phobia -plegia pleurpneum-, pneumat- -poiesis, -poietic polypostposterpropseudpsychpyelorerenretrrhe-, -rrhea rhin- -rrhage, -rhagia -rrhaphy salpingscirrh- -sclerosis -scope -scopy semisoma-, somatsphygmsplenspondylstenstethsubsupersupratachytel-, teletend-, tenthorac-, thoracithromb- -tomy transtrich-, trichitympanultrauniureterurethr- -uria vasvenvesic- surrounding fixation throat (pharynx) vein fear paralysis pleura lung; air formation many; much after; behind back; behind before; forward false mind renal pelvis back; again kidney behind; back flow nose bursting forth of blood suture fallopian tube; auditory tube hard hardening instrument for visual examination visual examination half body pulse spleen vertebra narrowness chest below above, superior above, upper fast complete tendon chest; pleural cavity clot process of cutting across hair tympanic membrane beyond; excess one ureter urethra urination vessel; duct vein urinary bladder

5 Web Sites CHAPTER 1 CMS AAMA AHIMA AAPC ACAP CHAPTER 2 Disability insurance CHAPTER 3 Kaiser Permanente Medical Data International NCQA Report Card HealthEast IDS NCQA JCAHO CHAPTER 4 Government regulators CHAPTER 5 Federal Register CMS press releases Trailblazer Health Enterprises

6 CodeCorrect State departments of health CMS listservs Medicare Part-B listserv Medicare training CMS/HIPAA OIG Fraud Prevention & Detection CCI Edits Manual from NTIS AdminaStar Federal, Inc. Medicare s National CCI Edits CCI edits (private vendor software) EncoderPro software ANSI ASC X12N 837 implementation guides Retail pharmacy standards CMS Standard EDI Enrollment Form Administrative Simplification (HIPAA) HHS Office for Civil Rights Business associate contract provisions CHAPTER 6 Delmar Learning ICD-9-CM Updates ICD-9-CM on CD-ROM National Uniform Claim Committee National Uniform Billing Committee ASC X12 (HIPAA Administrative Simplification) Federal Register ICD-9-CM and ICD-10-CM development (NCHS) ICD-10-PCS development (NCVHS) ICD-10 development (WHO) Coding Updates (Medicode) icd10.asp CHAPTER 7 CPT Coding Manual (Delmar Learning) CPT Coding Manual (AMA) E/M Documentation Guidelines Specialty exam scoresheets E/M Coding Tools Family Practice Management newsletter

7 CHAPTER 8 HCPCS information Medicare Carrier Manual (MCM) CHAPTER 9 Coverage Issues Manual (CIM) and Medicare Carriers Manual (MCM) CHAPTER 10 No Web sites CHAPTER 11 No Web sites CHAPTER 12 No Web sites CHAPTER 13 BCBS health care news CHAPTER 14 Medicare physician fee schedules RBRVS information Medicare consumer information Medicare downloadable files Intermediary-Carrier Directory CHAPTER 15 Medicaid publications State Medicaid toll-free numbers CHAPTER 16 TRICARE manuals CHAMPVA TRICARE Dental Program TRICARE Pharmacy Program TRICARE Supplemental Plan plans.cfm

8 CHAPTER 17 US Federal Mine Safety laws OSHA Federal workers compensation programs State workers compensation Web sites

9 UB-92 INTRODUCTION This appendix provides an introduction to the use of the UB-92 (Uniform Bill, implemented in 1992) claim for institutional services (e.g., hospitals and skilled nursing facilities). UB-92 The UB-92 claim contains data entry blocks called form locators (FLs) that are similar to the CMS-1500 claim blocks used to input information about procedures or services provided to a patient. While some institutions actually complete the UB-92 claim (Figure IX-1) and submit it to third-party payers for reimbursement, most perform data entry of UB-92 information using commercial software (Figure IX-2). What this means is most institutions do not actually complete a UB-92 claim for submission to a payer (unlike providers who usually complete the CMS-1500 claim either manually or onscreen using a software package). Instead, personnel who render services to institutional patients (e.g., nursing, laboratory or radiology) enter UB-92 data into the commercial software product. The data resides in the patient s computerized account, and upon discharge of the patient from the institution, the data is verified by billing office personnel and transmitted electronically either directly to the third-party payer or (more likely) to a clearinghouse that processes electronic claims by editing and validating them to ensure that they are error-free, reformatting them to the specifications of the payer, and submitting them electronically to the appropriate payer. EXAMPLE: During an inpatient admission, the attending physician writes an order in the patient s record for a blood glucose level to be performed by the laboratory. The patient s nurse processes the order by contacting the laboratory (e.g., telephone or computer message), which sends a technician to the patient s room to perform a venipuncture (blood draw, or withdrawing blood from the patient s arm using a syringe). The blood specimen is transported to the laboratory by the technician where the blood

10 FIGURE IX-1 Sample UB-92 claim (Reprinted according to CMS s reuse policy at

11 FIGURE IX-2 Sample data entry screen using UB-92 electronic data interchange software (Permission to reprint granted by Remora Software, Inc.) glucose test is completed. The technician enters the results into the patient record information technology (IT) system using a computer terminal. At the same time, the UB-92 data elements are input into the patient account IT system using a computer terminal. This data resides in the patient s computerized account until it is verified by the billing office (at patient discharge) and is then transmitted to a clearinghouse that processes the claim and submits it to the third-party payer. The clearinghouse also uses the network to send an acknowledgment to the institution upon receipt of the submitted claim. UB-92 Claim Development and Implementation Institutional and other selected providers submit UB-92 (CMS-1450) claim data (Figure IX-2) to payers for reimbursement of patient services. The National Uniform Billing Committee (NUBC) is responsible for developing data elements reported on the UB-92 in cooperation with State Uniform Billing Committees (SUBCs). NOTE: UB-92 claim data for Medicare Part A reimbursement is submitted to fiscal intermediaries (FIs), which are private insurance companies contracted by CMS to serve as the financial agent between providers and the federal government for the purpose of handling Medicare Part A reimbursement. The FI processes payments for hospitals, skilled nursing facilities, home health and hospice agencies, dialysis facilities, rehabilitation facilities, and rural health clinics. HINT: The role of the FI is similar to that of the Medicare carrier associated with Medicare Part B claims processing.

12 National Uniform Billing Committee (NUBC) Like the role of the National Uniform Claims Committee (NUCC) in the development of the CMS claim, the National Uniform Billing Committee (NUBC) is responsible for identifying and revising data elements (information entered into UB-92 form locators or submitted by institutions using electronic data interchange), and it originally designed the first uniform bill (called the UB-82 because of its 1982 implementation date). The current claim is called the UB-92 because it was implemented in The NUBC was created by the American Hospital Association (AHA) in 1975 and is represented by major national provider (e.g., AHA State Hospital Association Representatives) and payer (e.g., Blue Cross and Blue Shield Association) organizations. The intent was to develop a single billing form and standard data set that could be used by all institutional providers and payers for health care claims processing. In 1982, the NUBC voted to accept the UB-82 and its data set (a compilation of data elements that are reported on the uniform bill) for implementation as a national uniform bill. Once the UB-82 was adopted, the focus of the NUBC shifted to the state level, and a State Uniform Billing Committee (SUBC) was created in each state to handle implementation and distribution of state-specific UB-82 manuals (that contained national guidelines along with unique state billing requirements). When the NUBC established the UB-82 data set design and specifications, it also implemented an evaluation process through 1990 to determine whether the UB-82 data set was appropriate for third-party payer claims processing. The NUBC surveyed SUBCs to obtain suggestions for improving the design of the UB-82, and the UB-92 was implemented in 1992 to incorporate the best of the UB-82 with data set design improvements (e.g., providers no longer need to include as many attachments to UB-92 claims submitted). Data Specifications for the UB-92 When reviewing data specifications for the UB-92, the NUBC balances the payers need to collect information against the burden of providers to report that information. In addition, the administrative simplification principles required of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) are applied when developing data elements. Each data element required for reporting purposes is assigned to a unique UB-92 form locator (FL), which is the designated space on the claim identified by a unique number and title, such as the patient name in FL12 (Refer to Figure IX-1). UB-92 Claim Submission Whether completed manually (Figure IX-1) or using on-screen software (Figure IX-2), the UB-92 claim contains 86 form locators (Table IX-1). The data is entered according to third-party payer guidelines that contain instructions for completing the UB-92. Providers that submit the UB-92 claim (or UB-92 data elements in EDI format) include: ambulance companies. ambulatory surgery centers (ASC). home health care agencies (HHA). hospice organizations. hospitals (emergency department, inpatient, and outpatient services). psychiatric drug/alcohol treatment facilities (inpatient and outpatient services). skilled nursing facilities (SNFs). subacute facilities. stand-alone clinical/laboratory facilities. walk-in clinics. The UB-92 (CMS-1450) and its data elements serve the needs of many third-party payers, and while some payers do not collect certain data elements, it is important to capture all NUBCapproved data elements for audit trail purposes. In addition, NUBC-approved data elements are reported by facilities that have established coordination of benefits agreements with the payers. NOTE: All Medicare claims are currently submitted either manually on the UB-92 paper claim, or processed according to electronic data interchange (EDI) guidelines. Form locator definitions

13 TABLE IX-1 UB-92 form locators and brief description of information to be entered FORM BRIEF DESCRIPTION OF FORM BRIEF DESCRIPTION OF LOCATOR INFORMATION TO BE LOCATOR INFORMATION TO BE ENTERED ON THE UB-92 ENTERED ON THE UB-92 1 Provider Name, Address & Telephone # 46 Units of Service 2 Unlabeled Field - State Use 47 Total Charges (by Revenue Code Category) 3 Patient Control Number (Account Number) 48 Non-Covered Charges 4 Type of Bill 49 Unlabeled Field - National Use 5 Federal Tax Number 50A-C Payer Identification 6 Statement Covers Period 51A-C Provider Number 7 Covered Days 52A-C Release of Information Certification Indicator 8 Non-Covered Days 53A-C Assignment of Benefits Certification Indicator 9 Coinsurance Days 54A-C, P Prior Payments - Payers and Patient 10 Lifetime Reserve Days 55A-C, P Estimated Amount Due 11 Unlabeled Field - State Use 56 DRG Number and Grouper ID 12 Patient Name 57 Unlabeled Field - National Use 13 Patient Address 58A-C Insured s Name 14 Patient Birthdate 59A-C Patient s Relationship to Insured 15 Patient Sex 60A-C Health Insurance Claim Identification Number 16 Patient Marital Status 61A-C Insured Group Name 17 Admission Date 62A-C Insurance Group Number 18 Admission Hour 63A-C Treatment Authorization Code 19 Type of Admission 64A-C Employment Status Code 20 Source of Admission 65A-C Employer Name 21 Discharge Hour 66A-C Employer Location 22 Patient Status 67 Principal Diagnosis Code 23 Medical/Health Record Number Other Diagnosis Codes Condition Codes 76 Admitting Diagnosis 31 Unlabeled Field - National Use 77 External Cause of Injury Code (E-Code) 32-35a,b Occurrence Codes and Dates 78 Principal Diagnosis Code 36a,b Occurrence Span Codes and Dates 79 Procedure Coding Method Used 37 Internal Control Number (ICN) 80 Principal Procedure Code and Date 38 Responsible Party Name and Address 81A-E Other Procedure Codes and Dates 39-41a-d Value Codes and Amounts 82a-b Attending Physician ID 42 Revenue Code 83a-b Other Physician ID 43 Revenue Description 84 Remarks 44 HCPCS/Rates 85 Provider Representative Signature 45 Service Date 86 Date Bill Submitted (Reprinted according to content reuse policy at

14 are identical and in some situations, the electronic claim contains more characters than the corresponding item on the paper form. UB-02 The National Uniform Billing Committee (NUBC) is working on the proposed UB-02, which is scheduled to replace the UB-92. (The implementation date has not yet been announced.) Revisions will emphasize clarification of definitions for data elements and codes to eliminate amibiguity and to create consistency. The UB-02 will also address emergency department (ED) coding and data collection issues to respond to state public health reporting systems. The NUBC continues to emphasize the need to stay involved so that data sources can continue to support public health data reporting needs.

15 Dental Claims Processing INTRODUCTION Dental benefits programs offer a variety of options in the form of either feefor-service or managed care plans that reimburse a portion of a patient s dental expenses and may exclude certain treatments (e.g., dental sealants). It is, therefore, important for the insurance specialist to become familiar with the specifics of dental plans in which the dental professional participates. It is equally important to become familiar with dental terminology (Table X-1). DENTAL CLAIMS PROCESSING Dental claims are submitted on the American Dental Association (ADA) approved claim and instructions (Table X-2) should be carefully followed. Dental offices also have the option of submitting electronic claims according to HIPAA s electronic transaction standard, ASC Xl2N 837 v.4010 Health Care Claim: Dental. Dental treatment is reported using codes assigned from the Current Dental Terminology, 4th Edition (CDT-4). CDT-4 is published by the American Dental Association (ADA), which ensures that codes are: created according to a standard format. at an appropriate level of specificity. uniformly applied to dental treatment. used to report dental procedures. The American Dental Association periodically reviews and revises CDT-4 to update codes according to recognized changes in dental procedures. Published revisions are implemented biannually, at the beginning of oddnumbered years. (CDT-4 codes were reported effective January 1, 2003.) CDT-4 contains the following features: codes and descriptions a section on implant-supported prosthetics

16 glossaries of dental and dental benefit terminology the new ADA claim an introduction to the Systematized Nomenclature of Dentistry (SNODENT). SNODENT contains standard terms to describe dental disease, captures clinical detail and patient characteristics, and allows for the analysis of patient care services and outcomes. NOTE: CDT-5 is being developed for implementation in TABLE X-1 Glossary of common dental terms DENTAL TERM American Academy of Periodontology (AAP) American Academy of Pediatric Dentistry (AAPD) Alliance for the Best Clinical Practices in Dentistry (ABCPD) abscess American Dental Association (ADA) Academy of General Dentistry (AGD) amalgam attrition baby bottle tooth decay bitewing radiograph bruxism calculus caries crown deciduous teeth endentulous DEFINITION dedicated to advancing the art and science of periodontics and improving the periodontal health of the public dedicated to improving and maintaining the oral health of infants, children, adolescents, and persons with special health care needs organization that encourages development of evidence-based prevention and treatment protocols through the process of organizing focused seminars acute or chronic, localized inflammation associated with tissue destruction promotes public health through commitment of member dentists to provide high quality oral health care and promotes accessible oral health care serves needs and represents interests of general dentists alloy used in direct dental restorations; also called a silver filling normal wearing away of the surface of a tooth from chewing severe decay in baby teeth due to sleeping with a bottle of milk or juice; natural sugars from drinks combine with bacteria in the mouth to produce acid that decays teeth X-rays of top and bottom molars and premolars involuntary clenching or grinding of teeth hard deposit of mineralized material that adheres to teeth; also called tarter or calcified plaque tooth decay artificial covering of a tooth with metal, porcelain, or porcelain fused to metal baby teeth or primary teeth having no teeth (continues)

17 TABLE X-1 (continued) DENTAL TERM DEFINITION endodontics fluoride gingivitis gum disease halitosis malocclusion orthodontics Prevent Abuse and Neglect through Dental Awareness (PANDA) panoramic radiograph pedodontics periodontics periodontitis plaque prophylaxis prosthodontics radiograph scaling sealant supernumerary tooth tarter dental specialty concerned with treatment of the root and nerve of a tooth chemical compound that prevents cavities and makes tooth surface stronger inflammation of gums surrounding teeth, caused by buildup of plaque or food see periodontitis bad breath improper alignment of biting or chewing surfaces of upper and lower teeth dental specialty concerned with straightening or moving misaligned teeth and/or jaws with braces and/or surgery educational program that educates oral health professionals about child abuse and helps them learn how to diagnose and report potential abuse situations to appropriate authorities single, large X-ray of jaws taken by a machine that rotates around the head dental specialty concerned with treatment of children; also called pediatric dentistry dental specialty concerned with treatment of gums, tissue, and bone that supports the teeth inflammation and loss of connective tissue of the supporting or surrounding structure of the teeth; also called gum disease bacteria containing substance that collects on the surface of teeth, which can cause decay and gum irritation when not removed by daily brushing and flossing professional cleaning to remove plaque, calculus, and stains dental specialty concerned with restoration and/or replacement of missing teeth with artificial materials X-ray removal of plaque, calculus, and stains from teeth thin plastic material used to cover biting surface of a child's tooth extra tooth see calculus

18 TABLE X-2 Instructions for completing ADA Dental Claim, 2002 BLOCK Header Information INSTRUCTIONS Block 1 Block 2 Enter an X in the appropriate box. Select the Statement of Actual Services to obtain reimbursement for services provided. Select the Request for Predetermination/ Preauthorization to obtain preapproval of dental services. Select the EPSDT/Title XIX if the patient is covered by Medicaid s Early and Periodic Screening, Diagnosis, and Treatment program for persons under age 21. Enter the predetermination or preauthorization number assigned by the payer, if applicable. Otherwise, leave blank. Primary Payer Information Block 3 Enter the primary payer s name, address, city, state, and zip code. Other Coverage NOTE: Always complete Block 4. Complete Blocks 5-11 only if the patient has a secondary dental plan. Block 4 Enter an X in the NO box if the patient is not covered by another dental insurance plan, and go to Block 12. Enter an X in the YES box if the patient is covered by another dental insurance plan, and complete Blocks Remember! Complete Blocks 5-11 only if the patient has a secondary dental plan. Otherwise, leave Blocks 5-11 blank. Block 5 Block 6 Block 7 Block 8 Block 9 Block 10 Block 11 If the patient has secondary dental plan coverage, enter the complete name (last, first, middle initial, suffix) of the individual named as policyholder on the secondary plan. If the patient has secondary dental plan coverage, enter the secondary policyholder s date of birth as MMDDYYYY (without spaces). If the patient has secondary dental plan coverage, enter an X in the appropriate box to indicate the secondary policyholder s gender. If the patient has secondary dental plan coverage, enter the secondary policyholder s social security number (SSN) or dental plan identification number, whichever appears on the dental plan card. If the patient has secondary dental plan coverage, enter the secondary policyholder s dental plan number and group number (e.g., ). If the patient has secondary dental plan coverage, enter an X in the appropriate box to indicate the relationship of the primary policyholder to the secondary policyholder. If the patient has secondary dental plan coverage, enter the dental plan s name, address, city, state, and zip code. Primary Subscriber Information Block 12 Block 13 Block 14 Block 15 Enter the primary policyholder s complete name, address, city, state, and zip code. Enter the primary policyholder s date of birth as MMDDYYYY (without spaces). Enter an X in the appropriate box to indicate the primary policyholder s gender. Enter the primary policyholder s social security number (SSN) or dental plan identification number, whichever appears on the dental plan card. (continues)

19 TABLE X-2 (continued) BLOCK Block 16 Block 17 INSTRUCTIONS Enter the dental plan number and/or group number. NOTE: Plan number is also called certificate number. Enter the name of the primary policyholder s employer. Patient Information NOTE: Always complete Block 18. Complete Blocks only if the patient is not the primary policyholder (e.g., Self does not contain an X in Block 18). Block 18 Block 19 Block 20 Block 21 Block 22 Block 23 Enter an X in the appropriate box to indicate the relationship of the patient to the primary subscriber. If the patient is not the primary policyholder and if the patient is a full time student, enter an X in the FTS box. If the patient is a part time student, enter an X in the PTS box. If the patient is not a student, leave blank. If the patient is not the primary policyholder, enter the patient s complete name, address, city, state, and zip code. If the patient is not the primary policyholder, enter the patient s date of birth as MMDDYYYY (without spaces). If the patient is not the primary policyholder, enter an X in the appropriate box to indicate the patient s gender. If the patient is not the primary policyholder, enter the account number assigned to the patient by the dental practice. Record of Services Provided Block 24 Block 25 Block 26 Block 27 For each procedure performed, enter the date of service on a different line. NOTE: There is no UNITS/DAYS column on the ADA Dental Claim, Enter the area of oral cavity treated using the ANSI/ADA/ISO Specification No for Dentistry- Designation System for Teeth and Areas of the Oral Cavity, which provides a system for designating teeth or areas of the oral cavity using two digits. It also provides a system for designating surfaces of the teeth using letters of the alphabet. The system was created by the International Dental Federation (IDF) and approved by the World Health Organization (WHO). EXAMPLE: UL = Upper Left Quadrant UR = Upper Right Quadrant LR = Lower Right Quadrant LL = Lower Left Quadrant Enter the applicable ANSI ASC X12N code list qualifier JP or JO: JP = ADA s Universal/National Tooth Designation System (numbers teeth 1-32) JO = ANSI/ADA/ISO Specification No (numbers teeth 11-18, 21-28, 31-38, 41-48) Identify tooth/teeth number(s) when procedure directly involves a tooth (e.g., restoration, tooth extraction, root canal, crown, or dentition related surgical excision): Report a range of teeth by entering a hyphen between first and last tooth (e.g., 1-5) Report separate individual teeth by entering a comma between teeth numbers (e.g., 1, 3, 5) (continues)

20 TABLE X-2 (continued) BLOCK INSTRUCTIONS NOTE: Use numerical identification (1-32) for permanent teeth and capital letter identification (A-T) for primary teeth. Leave blank if treatment of a specific tooth (e.g., oral examination) is not performed. For supernumerary tooth numbering, contact the dental plan. Block 28 Block 29 Block 30 Block 31 Block 32 Block 33 When procedure(s) directly involve one or more tooth surface(s), enter up to five of the following codes (without spaces): B = Buccal F = Facial M = Mesial D = Distal L = Lingual O = Occlusal Enter the CDT procedure code for dental treatment provided. Enter terminology to describe the service provided. NOTE: If service is for a supernumerary tooth, enter the word supernumerary and include information to identify the closest numbered tooth. Enter the fee charged for the procedure. Enter other fees (e.g., state taxes where applicable, fees imposed by regulatory agencies). Enter the total of all fees reported on the claim. Missing Teeth Information Block 34 Block 35 Enter an X on each number that corresponds to a missing tooth. Enter additional applicable information (e.g., multiple supernumerary teeth). Authorizations Block 36 Block 37 Obtain patient/guardian signature and date, which authorizes payment and release of information to dental plan. Obtain policyholder s signature and date, which authorizes the dental plan to make payment directly to the provider (e.g., dentist). Ancillary Claim/Treatment Information Block 38 Block 39 Block 40 Block 41 Block 42 Enter an X in the appropriate box to indicate place of treatment. NOTE: ECF refers to extended care facility (e.g., nursing facility). Enter an X in the appropriate box if the claim has attached radiograph(s), oral image(s), and/or model(s). If nothing is attached to the claim, leave blank. Enter an X in the NO box if treatment is not for orthodontics, and go to Block 43. Enter an X in the YES box if treatment is for orthodontics, and complete Blocks 41 and 42. Enter the date appliance (e.g., braces) were placed as MMDDYYYY (without spaces). Leave blank if an X was entered in the NO box in Block 40. Enter a number that represents the remaining months of treatment (e.g., 26). Leave blank if an X was entered in the NO box in Block 40. (continues)

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