UHIN STANDARDS COMMITTEE Version Dental Claim Billing Standard J430

Transcription

1 UHIN STANDARDS COMMITTEE Version Dental Claim Billing Standard J430 Purpose: The purpose of the Dental Billing Standard, is to clearly describe the standard use of each Item Number (for print images) and its crosswalk to the HIPAA X0224A1 Dental implementation guide. UHIN Dental Billing Standard is compatible with all HIPAA requirements. Applicability: This Standard applies to all dental claims, pre-determinations, and encounters. Basic Concepts: Item Number use is derived from the ADA 2012 Dental claim form instructions. A crosswalk from the Item Numbers to the ASC X X224A1 Implementation Guide is listed showing loop and segment/element (e.g., 2010AA NM104 means Loop 2010AA, segment NM1, element 04). This standard adopts the ADA Dental Claim Form J430 as the only official Paper Dental Claim for paper claims. Detail: 1. Explanations on the use of each ADA Item Number (Box Number) are given below. Dental Claim Form completion instructions may be found at: s_2012.pdf 2. Explanations regarding the use of the ASC X12 data elements are given in the ASC X X224A1 implementation guide. 3. If an Item Number is marked Not cross walked this means that this data element is not carried in the X12 Electronic Format. 4. Any data elements required by X12 that do not have a designated Item Number are placed outside the structured form and are considered Out of Form. Commonly placed in the top Right Hand Corner of the Claim Form. Rationale for including additional data elements that are not found on the paper form: If an element is always or nearly always required to submit. 5. All Item Numbers required by the ASC X12 Dental Claim Implementation guide, are marked REQUIRED. Everything else is used under the conditions described in the implementation guide. Providers are responsible for knowing when certain Situational data elements are required. 6. All data edits on electronic data will conform to the edits outlined in the HIPAA implementation guide and addenda. 7. COB information should follow the CDT Standard and not be entered at the line level. You may indicate the amount the primary carrier paid in the Remarks field (Item # 35). 8. Claim forms must be type-written (computer generated, typed, machine generated, etc.). Hand-written claim forms may be returned. Implementation Issues: Providers may begin submitting the 2012 Dental Claim Form (J430) to Utah Payers beginning July 1, A dual-use period for the 2012 Dental Claim Form (J430) and the 2006 Dental Claim Form (J400) will extend from July 1, 2012 to March 31, Effective April 1, 2014, Utah Payers may only accept the 2012 Dental Claim Form (J430). 1

2 DATA OUTSIDE OF FORM NUMBERED ITEMS Claim Frequency Code REQUIRED Placement - Top Right First Line, Right Justified 2300 CLM05-3 Valid Values are: 1-ORIGINAL (Admit thru Discharge Claim) 6-CORRECTED (Adjustment of Prior Claim) 7-REPLACEMENT (Replacement of Prior Claim) 8-VOID (Void/Cancel of Prior Claim) Original Reference Number Payer Claim Control Number REQUIRED when the claim frequency code other than original is used Placement Top Right Second Line, Right Justified 2300 REF02 (REF01 = F8) Claim Filing Indicator Code - REQUIRED Placement - Top Right Third Line Right Justified 2000B SBR09 Please see the X X224 for valid values SECTION: Header Information Item Number 1 - TYPE OF TRANSACTION - REQUIRED Statement of Actual Services No Request for Predetermination/Preauthorization 2300 CLM19 EPSDT/Title XIX: 2300 CLM12 Valid Value 01 Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) or Child Health Assessment Program (CHAP) Item Number 2 - PREDETERMINATION/PREAUTHORIZATION NUMBER This number is assigned by the payer. If Statement of actual services in Item Number 1 is marked and a number is in Item 2, crosswalk the number: 2300 REF02 (REF01 = G1) 2

3 SECTION: Insurance Company/Dental Benefits Plan Information Item Number 3 - COMPANY/PLAN NAME, ADDRESS, CITY, STATE, ZIP CODE - REQUIRED 2010BB NM103, N3, N4 (Payer Name / Payer Address / Payer City, State, Zip Code) Payer Responsibility Sequence Number Place the code in the first position of item #3 2000B SBR01 Valid Values are: P - Primary S Secondary T Tertiary SECTION: Other Coverage Item Number 4 - OTHER DENTAL OR MEDICAL COVERAGE - REQUIRED If No (Skip items 5-11), If either box is marked (Complete items 5-11 for the applicable benefit plan), If Both (Complete items 5-11 for dental only) No Item Number 5 - NAME OF POLICYHOLDER/SUBSCRIBER IN #4 (Last Name, First Name, Middle Initial, Suffix) 2330A NM103, NM104, NM105, NM107 (Last, First, Middle, Suffix) Item Number 6 - DATE OF BIRTH (MM/DD/CCYY) No Item Number 7 - GENDER M (Male) F (Female) No Item Number 8 - POLICYHOLDER/SUBSCRIBER ID (SSN OR ID#) 2330A NM109 Item Number 9 - PLAN/GROUP NUMBER 2320 SBR03 3

4 Item Number 10 - PATIENT S RELATIONSHIP TO PERSON NAMED IN #5 (Self, Spouse, Dependent, Other) 2320 SBR02 Valid Values are: 18 - Self 01 - Spouse 76 - Dependant 21 - Unknown Item Number 11 - OTHER INSURANCE COMPANY/DENTAL BENEFIT PLAN NAME, ADDRESS, CITY, STATE, ZIP CODE 2330B NM103, N3, N4 (Name / Address/ City, State, Zip Code) SECTION: Policyholder/Subscriber Information Item Number 12 - POLICYHOLDER/SUBSCRIBER NAME ADDRESS, CITY, STATE, ZIP CODE - REQUIRED (Last Name, First Name, Middle Initial, Suffix) 2010BA NM103, NM104, NM105, NM107 (Last, First, Middle Initial, Suffix) 2010BA N3, N4 (Address/ City, State, Zip) Item Number 13 - DATE OF BIRTH - REQUIRED (MM/DD/CCYY) 2010BA DMG02 Item Number 14 GENDER (M, F) REQUIRED when the patient is the same person as the subscriber or when known. 2010BA DMG03 Output U if no box marked. Item Number 15 - POLICYHOLDER/SUBSCRIBER ID - REQUIRED (SSN OR ID#) Enter the unique identifying number assigned by the third-party payer (e.g. insurance company) to the person named in item # BA NM109 Item Number PLAN/GROUP NUMBER For Insurance Company Named in #3 2000B SBR03 Item Number EMPLOYER NAME For Insurance Company Named in #3 4

5 No SECTION: Patient Information Item Number 18 - RELATIONSHIP TO POLICYHOLDER/SUBSCRIBER IN #12 ABOVE If self is checked in item number 18 then patient = subscriber (bypass item number 19 through 22). If anything else, then patient subscriber. If the Patient = subscriber, then 2000B SBR02 18=Self If the patient subscriber, then 2000C PAT01 01=Spouse, 19=Dependent Child, 21=Unknown Item Number 19 - RESERVED FOR FUTURE USE Leave blank and skip to item #20. (#19 was previously used to report Student Status. ) No Item Number 20 - NAME - REQUIRED (LAST, FIRST, MIDDLE INITIAL, SUFFIX) 2010CA NM103, NM104, NM105, NM107 (Last, First, Middle Initial, Suffix) 2010CA N3, N4 (Address / City, State, Zip Code) Item Number DATE OF BIRTH - REQUIRED (MM/DD/CCYY) 2010CA DMG02 Item Number GENDER (M, F) REQUIRED when known 2010CA DMG03 Output U if no box marked. 5

6 Item Number PATIENT ID/ACCOUNT # (Assigned by Dentist) This number should be unique to the claim. It is used for financial reconciliation purposes. This item is strongly recommended CLM01 (Maximum number of characters to be supported is 20) SECTION: Record of Services Provided Item Number 24 - PROCEDURE DATE (MM/DD/CCYY) REQUIRED when Statement of Actual Services is checked in Item Number 1. Coordination of Benefit amounts are not carried in this box. Please see item # DTP03 (DTP01 = 472) Claim level date is sent for performed services (Not used for predetermination) 2400 DTP03 (DTP01 = 472) When a line service date is different than the claim level date Item Number 25 - AREA OF ORAL CAVITY 2400 SV304 Item Number 26 -TOOTH SYSTEM 2400 TOO01 Valid Value: JP - National Standard Tooth Numbering System Item Number 27 - TOOTH NUMBER(S) OR LETTER(S) 2400 TOO02 This box is also used to convey supernumerary teeth (See instructions provided by ADA in the CDT). Supernumerary Teeth 2300 NTE02 Item Number 28 - TOOTH SURFACE 2400 TOO03 Item Number 29 PROCEDURE CODE - REQUIRED 2400 SV

7 Item Number 29a - DIAGNOSIS CODE POINTER(S) The letter(s) from item 34 that identify the diagnosis code(s) applicable to the dental procedure. The primary diagnosis pointer is listed first SV311-1 through SV311-4 Item Number 29b Quantity The number of times (01-99) the procedure identified in item 29 is delivered to the patient on the date of service shown on item 24. The default value is SV306 Item Number 30 DESCRIPTION 2400 SV301-7 Item Number 31 FEE Usual and customary charge. REQUIRED when Statement of Actual Services is checked in Item Number SV302 Item Number 31a OTHER FEE(s) (State tax and other charges imposed by regulatory bodies) 2400 AMT02 Item Number 32 TOTAL FEE Amounts placed here are those allowed in payer to provider contract, otherwise not used (example sales Tax amount). The sum of all fees from lines in #31, plus any fee(s) entered in item #31a. Coordination of Benefit amounts are not carried in this box. Please see item # CLM02 SECTION: Missing Teeth Information Item Number 33 - MISSING TEETH INFORMATION An X is marked on the number of the missing tooth for identifying missing permanent dentition only DN201 (DN202 = M) Item Number DIAGNOSIS CODE LIST QUALIFIER Diagnosis code source: B = ICD-9-CM AB = ICD-10-CM (For dates of service on or after October 1, 2014) This information is REQUIRED when the diagnosis may have an impact on the adjudication of the claim. 7

8 2300 HI01-1 Item Number 34a DIAGNOSIS CODE(S) May enter up to four applicable diagnosis codes after each letter (A. D.). The primary diagnosis code is entered adjacent to the letter A. This information is REQUIRED when the diagnosis may have an impact on the adjudication of the claim HI01-2 through HI04-2 Item Number REMARKS This box is used to convey additional information including coordination of benefits (See instructions provided by ADA in the CDT). Coordination of Benefits - REQUIRED when prior insurance has processed this claim. COB Reporting is available ONLY at the Claim Level on paper. COB Reporting is available at the claim and line level on electronic claims CAS01 CAS19. The Group COB code, Adjustment Reason Code and the amount should be reported. REQUIRED when prior insurance has processed this claim. COB Example: Prior payer(s) payment (T) Patient Responsibility (PR:01) Prior payer(s) contractual write-off or adjustment amounts (CO:45) Please use the x12 reason codes for the adjustments returned in the Electronic or Paper EOB. T: 400,PR:01:100,CO:45: AMT02 (Prior Payer Amount Paid AMT01 = D) 2320 AMT02 (Remaining Patient Liability AMT01 = EAF) 2320 CAS02, CAS03 (Adjustment Amounts CAS01 = CO, CR, OA, PI) SECTION: Authorizations Item Number 36 - Patient Consent - REQUIRED 2300 CLM09 Valid Values are: I - Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes Y Yes Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim 8

9 Item Number 37 Subscriber s Signature - REQUIRED (Assignment of Benefits) 2300 CLM08 Valid Values are: Y - Yes N No W Not Applicable (when patient refuses to assign benefits) SECTION: Ancillary Claim/Treatment Information Item Number 38 - PLACE OF TREATMENT - REQUIRED For Provider s Office Box and ECF Box mark X For Hospital Box or Other Box enter X12 valid value (See Code Source CLM 05-1 Valid Values are: 11 - Provider Office 12 - Home 21 - Inpatient Hospital 22 - Outpatient Hospital 31 Skilled Nursing Facility 32 Nursing Facility Other Use appropriate code (Place of Service Codes for Professional Claims). Item Number 39 - NUMBER OF ENCLOSURES (00 TO 99) Y or N to indicate whether or not there are enclosures of any type included with the claim submission (e.g., radiographs, oral images, models) PWK01, PWK02, PWK05, PWK06 Item Number 40 - IS TREATMENT FOR ORTHODONTICS? - REQUIRED NO (Skip Items 41-42) No YES (Complete Items 41-42) No Item Number 41- DATE APPLIANCE PLACED (MM/DD/CCYY) 2300 DTP03 (DTP01 = 452) Item Number 42 - MONTHS OF TREATMENT REMAINING 2300 DN102 9

10 Item Number 43 - REPLACEMENT OF PROSTHESIS? No, Yes (Complete Item 44) No 2400 SV305 Valid values are: R Replacement Item Number 44 - DATE PRIOR PLACEMENT (MM/DD/CCYY) REQUIRED when box #43 is marked Yes DTP03 (DTP01 = 441) Item Number 45 - TREATMENT RESULTING FROM (Occupational Illness/Injury, Auto accident, Other Accident) 2300 CLM11-1, CLM11-2 Valid values are: EM - Employment (Occupational illness/injury) AA - Auto OA - Other Accident For those claims that require a Property and Casualty claim number (event number), place in top section of box. 2010CA REF02 (REF01 = Y4) 2010CA REF02 (REF01 = Y4) Item Number 46 - DATE OF ACCIDENT (MM/DD/YY) 2300 DTP03 (DTP01 = 439) Item Number 47 - AUTO ACCIDENT STATE Required if CLM-11 has value of AA 2300 CLM11-4 SECTION: Billing Dentist or Dental Entity Item Number 48 - NAME, ADDRESS, CITY, STATE, ZIP CODE - REQUIRED Must be the physical location of Service as identified in payer contract (Cannot be a PO Box). 10

11 Billing Provider Name 2010AA NM103, NM104, NM105, NM107 (Last, First, Middle, Suffix) Billing Provider Address X12 Cross Walk 2010AA N301 Billing Provider City, State, Zip Code X12 Cross Walk 2010AA N401, N402, N403 Item Number 49 - NPI - REQUIRED Enter the NPI that corresponds with the information for the Billing Provider sent in item # AA NM109 (NM108 = XX) Item Number 50 - LICENSE NUMBER 2010 AA REF02 (REF01 = OB) Item Number 51 - SSN OR TIN - REQUIRED 2010AA REF02 (REF01 = EI or SY) Item Number 52 - PHONE NUMBER 2010AA PER04 Item Number 52a - ADDITIONAL PROVIDER ID NOT USED SECTION: Treating Dentist And Treatment Location Information Item Number 53 TREATING DENTIST - REQUIRED Print name of Treating Dentist (Rendering). 2310B NM103, NM104, NM105, NM107 (NM101 = 82) Item Number 54 - NPI - REQUIRED 2310B NM109 (NM108 = XX) Item Number 55 - LICENSE NUMBER 2010AA REF02 (REF01 = OB) 11

12 Item Number 56 - ADDRESS, CITY, STATE, ZIP Address X12 Cross Walk 2010AA N301 City, State, Zip Code X12 Cross Walk 2010AA N401, N402, N403 Item Number 56a - PROVIDER SPECIALTY CODE May be required by payers for contract matching (Taxonomy). 2310B PRV03 (PRV02 = ZZ) Item Number 57 - PHONE 2010AA PER04 Item Number 58 -ADDITIONAL PROVIDER ID NOT USED History: (MM/DD/YY) Original A 3.1 A* 3.2 A* 3.4 A* 3.5 ORIGINATION DATE 09/29/2009 4/4/ /25/2013 APPROVAL DATE 12/02/2009 5/18/2011 1/9/2014 EFFECTIVE DATE 01/02/2010 6/18/2011 2/5/2014 * A = Amendment 12

13 APPENDIX A Claim Form 13

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15 Appendix B Claim Form Billing Example 15

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