TMPPM 2010 > Volume 1, General Information > Section 6: Claims Filing > 2006 American Dental Association (ADA) Dental Claim Filing Instructions > 2006 ADA Dental Claim Form Instruction Table

   
 

6.7.4 2006 ADA Dental Claim Form Instruction Table

The following table is an itemized description of the questions appearing on the form. Thoroughly complete the 2006 ADA Dental claim form according to the instructions in the table to facilitate prompt and accurate reimbursement and reduce follow-up inquiries.

ADA Block No.
ADA Description
Instructions

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" on page B-111.

2

Predetermination/Preauthorization Number

Enter prior authorization number if assigned by Medicaid.

3

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

Enter TMHP and the address.

Refer to: "Written Communication With TMHP" on page XX.

4

Other Dental or Medical Coverage?

Check No if no other dental or medical coverage (skip Blocks 5-11). Check Yes if dental or medical coverage is available other than Texas Medicaid coverage, and complete Blocks 5-11.

5-11

Other Coverage Information

General notes:

Enter the information for non-Medicaid insurance coverage.

Enter the information for the policyholder or subscriber, not necessarily the patient. May be a parent or legal guardian of the patient receiving treatment.

5

Name of Policyholder/Subscriber in # 4

Enter the policyholder/subscriber name.

6

Date of Birth (MM/DD/CCYY)

Enter policyholder/subscriber eight-digit date of birth (MM/DD/YYYY).

7

Gender

Check the appropriate box for the policyholder/subscriber gender

8

Policyholder/Subscriber ID

Enter policyholder/subscriber identifier.

9

Plan/Group Number

Enter policyholder/subscriber plan/group number.

10

Patient's Relationship to Person Named in # 5

Enter the patient's relationship to policyholder/subscriber.

11

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

Enter the contact information for the insurance company providing the non-Medicaid coverage.

12

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

Enter the Medicaid patient's last name, first name, and middle initial as printed on the Medicaid identification form.

13

Date of Birth (MM/DD/CCYY)

Enter the Medicaid patient's date of birth (MM/DD/YYYY).

14

Gender

Check the appropriate box for the Medicaid patient's gender.

15

Policyholder/Subscriber ID

Enter nine-digit patient number from the Medicaid identification form.

16

Plan/Group/Number

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

17

Employer Name

Not applicable to Texas Medicaid.

18

Relationship to Policyholder/Subscriber in # 12 Above

Not applicable to Texas Medicaid.

19

Student Status

Not applicable to Texas Medicaid.

For exceptions to periodicity refer to Block 35.

20

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

Not applicable to Texas Medicaid.

21

Date of Birth (MM/DD/CCYY)

Not applicable to Texas Medicaid.

22

Gender

Not applicable to Texas Medicaid.

23

Patient ID/Account # (Assigned by Dentist)

Optional: Enter the patient identification number if it is different than the subscriber/insured's identification number.

Used by dental office to identify internal patient account number.

24

Procedure Date (MM/DD/CCYY)

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

25

Area of Oral Cavity

Not applicable to Texas Medicaid.

26

Tooth System

Not applicable to Texas Medicaid.

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" on page 19-10.

28

Tooth Surface

Enter Surface ID as required for procedure code.

Refer to: "Tooth Identification (TID) and Surface Identification (SID) Systems" on page 19-10.

29

Procedure Code

Use appropriate Current dental terminology (CDT) procedure code.

30

Description

Enter brief description for the CDT procedure code.

31

Fee

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

32

Other Fee(s)

Enter any amount paid by an insurance company or other sources known at the time of submission of the claim. Identify the source of each payment and date in Block 11. If the client makes a payment, the reason for the payment must be indicated in Block 11.

33

Total Fee

Enter the sum of all fees in Block 31.

For multi-page claims enter "continue" on initial and subsequent claim forms. Indicate the total of all charges on the last claim.

Note: Indicate the page number of the attachment (for example, page 2 of 3) in the top right-hand corner of the form.

34

Place an X on each missing tooth

Place an X on the appropriate tooth number to identify each missing tooth.

35

Remarks

Use this space for: "

Explanation of exception to periodicity.

"The facility name and address if the place of treatment indicated in Block 38 is not the provider's office.

Explanation of emergency if indicated in Block 45.

To provide more information such as reports for local orthodontia codes, 999 codes, multiple supernumerary teeth, or remarks.

36

Patient/Guardian signature

Not applicable to Texas Medicaid.

37

Subscriber signature

Not applicable to Texas Medicaid.

38

Place of Treatment

Check only Provider's Office or Hospital box.

Do not use ECF and Other.

Check the Hospital box for services rendered in a day surgery facility.

39

Number of Enclosures

Enter the number of enclosures (attachments) accompanying the claim, if applicable.

Texas Medicaid does not require radiographs with claims.

Exception: When requested, radiographs may be submitted with appeals.

40

Is Treatment for Orthodontics?

Check Yes or No as appropriate.

41

Date Appliance Placed

Not applicable to Texas Medicaid.

42

Months of Treatment Remaining

Not applicable to Texas Medicaid.

43

Replacement of Prosthesis?

Not applicable to Texas Medicaid.

44

Date Prior Placement

Not applicable to Texas Medicaid.

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 Texas Medicaid.

47

Auto Accident State

Not applicable to Texas Medicaid.

48

Name, Address, City, State, ZIP Code

Enter the name and address of the billing group or individual provider. Do not enter the name and address of a provider employed within a group.

49

NPI

Enter the billing provider's NPI for a group or an individual. Do not enter the NPI for a provider employed within a group.

50

License Number

Not applicable to Texas Medicaid.

51

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

Not applicable to Texas Medicaid.

52

Telephone Number

Enter the area code and number for the billing group or individual Do not enter 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. Do not enter the TPI for a provider employed within a group.

53

Signed (Treating Dentist)

Required-Signature of treating dentist or authorized personnel.

Billing services may print "Signature on File" in place of the provider's signature if the billing service obtains and retains on file a letter signed by the provider authorizing this practice.

Refer to: "Provider Signature on Claims".

54

NPI

Enter the NPI for the dentist enrolled as part of a group who treated the patient.

Does not apply to individual providers.

55

License Number

Not applicable to Texas Medicaid.

56

Address, City, State, ZIP Code

Not applicable to Texas Medicaid.

56A

Provider Specialty Code

This block is optional.

57

Telephone Number

Not applicable to Texas Medicaid.

58

Additional Provider ID

Required
Enter the TPI for the dentist's enrolled as part of a group who treated the patient.

Does not apply to individual providers.


Texas Medicaid & Healthcare Partnership
CPT only copyright 2009 American Medical Association. All rights reserved.
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