1

Type of Transaction

For Texas Medicaid, check the Statement of Actual Services Box. The other two boxes are not applicable. Do not use the 2006 ADA Dental Claim Form as a Texas Medicaid Program Prior Authorization form.

Refer to: "THSteps Dental Mandatory Prior Authorization Request Form".

2

Predetermination/Preauthorization Number

Enter prior authorization number if assigned by Medicaid.

3

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

Enter name and address of Texas Medicaid 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 Texas Medicaid Program coverage, and complete Blocks 5-11.

5

Name of Policyholder/Subscriber in # 4

Subscriber name if non-Medicaid insurance. 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 insured's eight-digit date of birth (MM/DD/CCYY) if non-Medicaid insurance. 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 insured's correct gender if non-Medicaid insurance. This line refers to the insured and is not necessarily the client. May be a parent or legal guardian of the client receiving treatment.

8

Policyholder/Subscriber ID

Enter insured's subscriber identifier if non-Medicaid insurance. 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 insured's plan/group number if non-Medicaid insurance. 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

Patient's Relationship to Person Named in # 5

Enter insured's relationship to primary subscriber if non-Medicaid insurance. 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 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 Texas Medicaid Identification Form (Form H3087).

13

Date of Birth (MM/DD/CCYY)

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

14

Gender

Check client's correct gender.

15

Policyholder/Subscriber ID

Enter client's Medicaid number.

16

Plan/Group/Number

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

17

Employer Name

Not applicable to the Texas Medicaid Program.

18

Relationship to Policyholder/Subscriber in # 12 Above

Not applicable to the Texas Medicaid Program.

19

Student Status

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

Note: Block 19 may be left blank on claims submitted for emergency/trauma.

20

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

Not applicable to the Texas Medicaid Program.

21

Date of Birth (MM/DD/CCYY)

Not applicable to the Texas Medicaid Program.

22

Gender

Not applicable to the Texas Medicaid Program.

23

Patient 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 to the Texas Medicaid Program.

26

Tooth System

Not applicable to the Texas Medicaid Program.

27

Tooth Number(s) or Letter(s)

Enter the Tooth ID as required for procedure code.

Refer to: "Tooth Identification (TID) and Surface Identification (SID) Systems" .

28

Tooth Surface

Enter Surface ID as required for procedure code.

Refer to: "Tooth Identification (TID) and Surface Identification (SID) Systems" .

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

Patient/Guardian signature

Not applicable to the Texas Medicaid Program.

37

Subscriber signature

Not applicable to the Texas Medicaid 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 Texas Medicaid 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

Not applicable to the Texas Medicaid Program.

42

Months of Treatment Remaining

Not applicable to the Texas Medicaid Program.

43

Replacement of Prosthesis?

Not applicable to the Texas Medicaid Program.

44

Date Prior Placement

Not applicable to the Texas Medicaid Program.

45

Treatment Resulting from (Check applicable box)

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

46

Date of Accident (MM/DD/CCYY)

Not applicable to the Texas Medicaid Program.

47

Auto Accident State

Not applicable to the Texas Medicaid 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

Optional
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 to the Texas Medicaid Program.

51

Social Security Number (SSN) or Tax Identification Number (TIN)

Not applicable to the Texas Medicaid 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 nine-digit TPI assigned to the billing dentist or dental entity (not the CSHCN Services Program provider employed within a group).

53

Signed (Treating Dentist)

Required-Signature of treating dentist or authorized personnel.

54

NPI

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

55

License Number

Not applicable to the Texas Medicaid Program.

56

Address, City, State, ZIP Code

Not applicable to the Texas Medicaid Program.

56A

Provider Specialty Code

This block is optional.

57

Telephone Number

Not applicable to the Texas Medicaid Program.

58

Additional Provider ID

Required
Enter performing dentist's (provider who treated the client) nine-digit TPI.