1

Type of Transaction (Mark all applicable boxes)

For the CSHCN Services Program, check Statement of Actual Services Box. The other two boxes are not applicable.

2

Predetermination/Preauthorization Number

Enter PAN if assigned by the CSHCN Services Program.

3

Company/Plan Name, Address, City, State, ZIP Code

Enter name and address of CSHCN Services Program Contractor payer where the claim is to be sent.

4

Other Dental OR Medical Coverage?

Leave blank if no other dental or medical coverage (skip Blocks 5-11). Check Yes if dental or medical coverage is available other than CSHCN Services Program coverage, and complete Blocks 5-11.

5

Name of Policyholder/Subscriber in #4

This line refers to the insured and is not necessarily the client. May be a parent or legal guardian of the client receiving treatment.

6

Date of Birth (MM/DD/CCYY)

Enter insureds eight-digit date of birth (MM/DD/CCYY). This line refers to the insured and is not necessarily the client. May be a parent or legal guardian of the client receiving treatment.

7

Gender

Check insureds correct gender. This line refers to the insured and is not necessarily the client. May be parent or legal guardian of client receiving treatment.

8

Policyholder/Subscriber ID (SSN or ID#)

Enter insureds subscriber identifier. This line refers to the insured and is not necessarily the client. May be a parent or legal guardian of the client receiving treatment.

9

Plan/Group Number

Enter insureds plan/group number. This line refers to the insured and is not necessarily the client. May be a parent or legal guardian of the client receiving treatment.

10

Client's Relationship to Person Named in #5

Enter insureds relationship to primary subscriber. This line refers to the insured and is not necessarily the client. May be a parent or legal guardian of the client receiving treatment.

11

Other Insurance Company/Dental Benefit Plan Name, Address, City, State, ZIP Code

Information on other insurance carrier, if applicable.

12

Policyholder/Subscriber Name (Last, First, Middle Initial, Suffix), Address, City, State, ZIP Code

Enter client's last name, first name, and middle initial exactly as written on the CSHCN Services Program Eligibility Form.

13

Date of Birth (MM/DD/CCYY)

Enter client's eight-digit date of birth (MM/DD/CCYY).

14

Gender

Check client's gender.

15

Policyholder/Subscriber ID (SSN or ID#)

Enter client's CSHCN Services Program number.

16

Plan/Group Number

Enter the benefit code, if applicable, of the billing or performing provider.

17

Employer Name

Not applicable for the CSHCN Services Program.

18

Relationship to Policyholder/Subscriber in #12 Above

Not applicable for the CSHCN Services Program.

19

Student Status

For exception to periodicity, check the full time student (FTS) box and provide a narrative explanation in Block 35.

20

Name (Last, First, Middle Initial, Suffix), Address, City, State, ZIP Code

Must put client name information, same as in Block 12.

21

Date of Birth (MM/DD/CCYY)

Must put client's eight-digit date of birth information, same as in Block 13.

22

Gender

Must put client gender information, same as in Block 14.

23

Client ID/Account #
(Assigned by Dentist)

Optional-Used by dental office to identify internal client account number. This block is not required to process the claim.

24

Procedure Date (MM/DD/CCYY)

Enter eight-digit date of service (MM/DD/CCYY).

25

Area of Oral Cavity

Not applicable for the CSHCN Services Program.

26

Tooth System

Not applicable for the CSHCN Services Program.

27

Tooth Number(s) or Letter(s)

Enter the Tooth ID as required for procedure code. Select the appropriate tooth number for permanent teeth (01-32 or the appropriate letter for primary teeth 0A through 0T).

28

Tooth Surface

Enter the Surface ID as required for procedure code using M (Mesial); F (Facial); B (Buccal or Labial); O (Occlusal); L (Lingual or Cingulum); D (Distal); and/or I (Incisal).

29

Procedure Code

Use appropriate Current Dental Terminology (CDT) procedure code.

30

Description

Enter brief description from the CDT procedure code.

31

Fee

Enter usual and customary charges for each line of service used. Charges must not be higher than the fees charged to private pay clients.

32

Other Fee(s)

Enter other fees (e.g., other insurance payment).

33

Total Fee

Total all fees in column under Block 31.

34

Place an "X" on each missing tooth

Place an X on each missing tooth as required for procedure code.

35

Remarks

Use the Remarks space for local orthodontia codes, a narrative explanation for exception to periodicity (Block 19), a facility name and address if the place of treatment (Block 38) is not a provider's office, an emergency narrative (Block 45), or additional information, such as reports for 999 codes or multiple supernumerary teeth, or remarks codes.

36

Client/Guardian signature

Not applicable for the CSHCN Services Program.

37

Subscriber signature

Not applicable for the CSHCN Services Program.

38

Place of Treatment

Check only Provider's office box or Hospital box. Use Hospital if a day surgery facility was used.

39

Number of Enclosures

The CSHCN Services Program does not require enclosures to accompany a claim. Do not submit radiographs with claims.

40

Is Treatment For Orthodontics?

Check Yes or No as appropriate.

41

Date Appliance Placed (MM/DD/CCYY)

Not applicable for the CSHCN Services Program.

42

Months of Treatment Remaining

Not applicable for the CSHCN Services Program.

43

Replacement of Prosthesis?

Not applicable for the CSHCN Services Program.

44

Date Prior Placement (MM/DD/CCYY)

Not applicable for the CSHCN Services Program.

45

Treatment Resulting from

Providers are required to check Other Accident box for emergency claim reimbursement. If Other Accident box is checked, information about the emergency must be provided in Block 35.

46

Date of Accident
(MM/DD/CCYY)

Not applicable for the CSHCN Services Program.

47

Auto Accident State

Not applicable for the CSHCN Services Program.

48

Name, Address, City, State, ZIP Code

Name and address of the billing group or individual provider (not the name and address of a provider employed within a group).

49

NPI

Enter required billing dentist's NPI for a group or an individual (not the NPI for a provider employed within a group).

50

License Number

Not applicable for the CSHCN Services Program.

51

SSN or TIN

Not applicable for the CSHCN Services Program.

52

Telephone Number

Enter area code and telephone number of billing group or individual (not the telephone number of a provider employed within a group).

52A

Additional Provider ID

Enter the TPI assigned to the billing dentist or dental entity (not the CSHCN Services Program employed within a group).

53

Signed (Treating Dentist)

Required signature of treating dentist or authorized personnel.

54

NPI

Enter the performing dentist's (provider who treated the client).

55

License Number

Not applicable for the CSHCN Services Program.

56

Address, City, State, ZIP Code

Not applicable for the CSHCN Services Program.

56A

Provider Speciality Code

This block is optional.

57

Telephone Number

Not applicable for the CSHCN Services Program.

58

Additional Provider ID

Required information-must enter nine-character TPI for the performing dentist (provider who treated the client) TPI.