Providers must attach a copy of the payer s EOB with the UnitedHealthcare Community Plan dental claim (2012 ADA form).

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1 UnitedHealthcare Community Plan (formerly APIPA) Medicaid Dental Claims and Billing Process Effective Dates of Service October 01, 2015 or after AHCCCS Provider Identification Number and NPI Number All UnitedHealthcare Community Plan in-network dental providers requesting reimbursement for services must be properly registered with AHCCCS and have a valid AHCCCS Physician/Dental or Health Care Provider Identification Number. Dental providers must communicate his or her NPI to health plans, clearinghouses, and AHCCCS before the compliance date. Acceptable Claim Formats Dental health professional providers must submit their claims in the following format: ADA Dental Claim Form 2012 (only any other forms will be rejected) Electronic claims submission via a clearinghouse, OR no-cost provider portal submission EDI/Electronic Claim UnitedHealthcare Community Plan dental department offers electronic claims submission for most of our contracted providers. Some of the benefits to filing your claims electronically are: Electronic confirmation of proof of receipt or notification if the claim is missing required information. Improvement of data integrity. Decreased turnaround time on claims processing. HIPAA compliant No more paper claim submissions associated with mailing costs Flexibility to submit claims at any time Training and technical support Electronic Payer ID GP133 1

2 Initial Claims Filings Time Limits UnitedHealthcare Community Plan requires that all initial claims be submitted within 90 days following the date the services are rendered. Medicaid is always the payer of last resort, therefore coordination of benefits with primary insurance, including Medicare, is required. Claims involving coordination of benefits must be submitted within 60 days from the date of Explanation of Benefits (EOB) from the primary and/or secondary payor. Providers must attach a copy of the payer s EOB with the UnitedHealthcare Community Plan dental claim (2012 ADA form). Dental Clean Claims A clean claim is a claim that has all the required fields entered according to AHCCCS guidelines: Beginning October 01, 2015 dates of service, all dental providers are required to bill on the 2012 ADA Form as appropriate, utilizing appropriate place of service coding (11-Office). Additionally, accompanying ICD10 diagnosis is required on all dental claims. Claims must include all appropriate covered procedure codes describing the services rendered. Completing the ADA 2012 Claim Form Claims Billing Address: UnitedHealthcare Community Plan of Arizona PO Box 2185 Milwaukee, WI The following instructions explain how to complete the revised ADA 2012 Claim Form. Fields are marked as required, required if applicable, or not required. 1 Type of Transaction Required Check statement of actual services and EPSDT/Title XIX if claim is for a recipient under age 21. If requesting a predetermination or preauthorization, check the appropriate box. 2

3 2 Predetermination/Preauthorization Number Required if applicable 3 Primary Payer Name and Address Required if applicable 4 Other Dental or Medical Coverage Required Check appropriate box to indicate whether recipient has third party coverage. 5 Subscriber s full Name Required if applicable 6 Subscriber s Date of Birth Required if applicable 7 Subscriber s Gender Required if applicable 8 Subscriber Identifier Required if applicable 9 Subscriber s Plan/Group Number Required if applicable 10 Patient s Relationship to Primary Subscriber Required if applicable 11 Other Carrier Name, full Address Required if applicable 12 Patient/recipient full Name and Address Required 13 Patient/recipient Date of Birth Required Enter the recipient s date of birth in MM/DD/CCYY format 14 Patient/recipient Gender Required 15 Patient/recipient Identifier Required Enter the recipient's AHCCCS ID number. Contact the AHCCCS Verification Unit if there are questions about eligibility or the AHCCCS ID number. (See Chapter 2, Eligibility). 16 Plan/Group Number Not required 17 Employer Name Not required 18 Relationship to Primary Subscriber in field 12 Not required 19 Student Status Not required 20 Name Not required 3

4 21 Date of Birth Not required 22 Gender Not required 23 Patient ID/Account Number Required 24 Procedure Date Required Enter the date of service in MM/DD/CCYY format. 25 Area of Oral Cavity Required Enter the code for the area of the oral cavity. Consult ANSI/ADA/ISO Specification No Designation System for Teeth and Areas of the Oral Cavity for codes. 26 Tooth System Required Enter JP when designating teeth using the ADA s Universal/National Tooth Designation system. Enter JO when using ANSI/ADA/ISO Specification No Tooth Number(s) or Letter(s) Required Enter the tooth number when the procedure directly involves a tooth. Use commas to separate individual tooth numbers. If a range of teeth is involved, use a hyphen to separate the first and last tooth in the range. If the same procedure is performed on more than a single tooth on the same date of service, report each procedure and tooth involved on separate lines of the claim form. 28 Tooth Surface Required Designate tooth surface(s) when the procedure directly involves one or more tooth surfaces. The following single letter codes are used to identify surfaces: B for buccal; D for distal; F for facial; I for incisal; L for lingual; M for mesial and O for occulusal. 29 Procedure Code Required Enter the appropriate procedure code from the CDT-4 Manual. 29a Diagnosis Code Pointer Required Enter the letter(s) from Field 34 that identify the diagnosis code(s) applicable to the dental procedure. List the primary diagnosis pointer first. 4

5 29b Quantity Required Enter the number of times (01 99) the procedure code in Field 29 is delivered to the patient on the date of service shown in Field 24. The default value is Description Required Enter the description of the procedure code billed in Field Fee Required Enter the fee for the procedure code billed in Field a. Other Fees Not required 32 Total Fee Required Enter the sum of all fees in Field Missing Teeth Required Place an X on each missing tooth. 34 Diagnosis Code List Qualifier Required Enter the qualifier AB for the ICD-10 diagnosis codes entered in Field 34a 34a Diagnosis Code(s) Required Enter up to 4 applicable diagnosis codes after each letter (A D). The primary diagnosis code is always entered as A. **Situationally Required: This information is required when the diagnosis may affect claim adjudication when specific dental procedures may minimize the risks associated with connection between the patient s oral and systemic health conditions.** 35 Remarks Not required 36 Parent/Guardian Signature and Date Not required 37 Subscriber Signature and Date Not required 38 Place of Treatment Required Enter the appropriate 2 digit Place of Service Code for professional claims (refer to the CPT Manual for a complete Place of Service Code listing) 5

6 39 Number of Enclosures Required if applicable 40 Is Treatment for Orthodontics? Required Check the appropriate box. If Yes is checked, complete Fields 41 and Date Appliance Placed Required if applicable 42 Months of Treatment Remaining Required if applicable 43 Replacement of Prosthesis Required Check the appropriate box. If Yes is checked, complete Field Date of Prior Placement Required if applicable If Yes is checked in Field 43, enter the date of prior placement in MM/DD/CCYY format. 45 Treatment Resulting From an Accident Required if applicable Check the appropriate box, as applicable. 46 Date of Accident Required if applicable Enter the date in MM/DD/CCYY format. 47 Auto Accident State Required if applicable Enter the 2 character abbreviation of the state where the accident occurred. 48 Billing Dentist/Dental Entity Name and Address Required Enter the full name and address of the billing provider or dental entity. 49 Provider ID (Group) Required Enter the AHCCCS provider ID of the billing provider or dental entity. 50 License Number Required Enter the license number of the billing provider or dental entity. 51 SSN or TIN Required Enter the Social Security Number or tax ID number of the billing provider or dental entity. 6

7 52 Phone Number Not required 52a Additional Provider ID Required if Applicable 53 Signature of Treating Provider Required The claim must be signed by the provider or his/her authorized representative. Rubber stamp signatures are acceptable if initialed by the provider representative. Enter the date on which the claim was signed. 54 NPI Required Enter the NPI of the treating provider. 55 License Number Required Enter the license number of the treating provider. 56 Address (Treating Provider) Required 56a Provider Specialty Code Not required 57 Phone Number (Treating Provider) Not required 58 Additional Provider ID Required if Applicable Resubmitting Dental Claims Claims not following clean claim billing guidelines as specified within this document, dates of service October 01, 2015 or after, will be rejected. The provider can resubmit a clean claim for reprocessing to: UnitedHealthcare Community Plan of Arizona Corrected Claims PO Box 1382 Milwaukee, WI Providers have up to 12 months from date of service to resubmit a claim. All claim resubmissions should include at a minimum the following information: Paper Format 7

8 Corrected claim form with resubmission written on the upper right hand corner of the 2012 ADA form. Copy of the remittance advice from the denied claim. Attach if applicable, a clear legible copy of the requested items such as medical records, primary EOB, invoice, or other documentation. Dental Claims Disputes Process Please follow these steps to ensure proper review of your dispute: Submit a cover letter indicating why you think your claims should not have underpaid or denied. Please include the following: Letter date Detailed reason for dispute Expected outcome/resolution Documentation supporting your position (medical/dental records, primary EOBs, explanation of benefits, and all other applicable documents) The patient s AHCCCS ID number, full name, and date of service The submitter s signature Submit dental claims disputes to: UnitedHealthcare Community Plan Claims Disputes Dept. 1 E. Washington St. Suite 900 Phoenix, AZ Time Limits for Filing Dental Claims Disputes A dental provider must submit any dispute challenging a claim denial or adjudication within 12 months (365 days) from the end date of service. Upon receipt, the Claims Dispute Coordinator will date stamp the request and that date will be considered the filing date for timeliness purposes. Escalation Process 1. Upon receipt of the denial or short payment EOB, the provider may call customer service at The provider will receive a tracking number for their inquiry. Please allow 30 days for resolution. 8

9 2. If there is no resolution in step one, the provider may call their health plan advocate at The provider advocate will notify the dental clinic representative if this can be corrected internally, or if a formal dispute will need to be filed. Additional Information Your Arizona Local Team Monica Estrada Dental Clinical & Administrative Coordinator Special Projects Management P F Monica_estrada@uhc.com Coral Rodriguez Dental Provider Relations Advocate P F coral_k_rodriguez@uhc.com Denise Clemente Dental Operations Manager P F denise_clemente1@uhc.com 9