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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 6: Claims Filing : 6.7 2006 American Dental Association (ADA) Dental Claim Filing Instructions : 6.7.4 2006 ADA Dental Claim Form Instruction Table

6.7.4
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.
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:
Form CH.12, “THSteps Dental Mandatory Prior Authorization Request Form” in Children’s Services Handbook (Vol. 2, Provider Handbooks).
Predetermination/Preau­thorization Number
Company/Plan Name, Address, City, State, ZIP Code
Refer to:
“Written Communication With TMHP” in “Preliminary Information” (Vol. 1, General Information).
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.
Other Coverage Information
Enter the information for the policyholder or subscriber, not necessarily the patient. May be a parent or legal guardian of the patient receiving treatment.
Name of Policyholder/Subscriber in # 4
Date of Birth (MM/DD/CCYY)
Policyholder/Subscriber ID
Patient’s Relationship to Person Named in # 5
Other Insurance Company/Dental Benefit Plan Name, Address, City, State, ZIP Code
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.
Date of Birth (MM/DD/CCYY)
Policyholder/Subscriber ID
Relationship to Policyholder/ Subscriber in # 12 Above
Name (Last, First, Middle Initial, Suffix), Address, City, State, ZIP Code
Date of Birth (MM/DD/CCYY)
Patient ID/Account # (Assigned by Dentist)
Optional: Enter the patient identification number if it is different than the subscriber/insured’s identification number.
Procedure Date (MM/DD/CCYY)
Refer to:
Subsection 4.2.9, “Tooth Identification (TID) and Surface Identification (SID) Systems” in Children’s Services Handbook (Vol. 2, Provider Handbooks).
Refer to:
Subsection 4.2.9, “Tooth Identification (TID) and Surface Identification (SID) Systems” in the Children’s Services Handbook (Vol. 2, Provider Handbooks).
Enter usual and customary charges for each service listed. Charges must not be higher than the fees charged to private pay clients.
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.
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.
Place an X on each missing tooth
"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.
Exception: When requested, radiographs may be submitted with appeals.
Is Treatment for Orthodontics?
Replacement of Prosthesis?
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.
Date of Accident (MM/DD/CCYY)
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.
Enter the billing provider’s NPI for a group or an individual. Do not enter the NPI for a provider employed within a group.
Social Security Number (SSN) or Tax Identifi­cation Number (TIN)
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.
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.
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.
Required
Enter the TPI for the dentist’s enrolled as part of a group who treated the patient.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2011 American Medical Association. All rights reserved.