June 2001: Dental Provisions #16

Claims Tips

• Submitting a corrected bill
• How to expedite claims for major services
• Invalid ADA code
• Difficult prophylaxis

Submitting a corrected bill

When submitting a corrected bill, it is important to clearly mark the claim as "Corrected Billing." Doing so alerts the claims specialist that additional information is included or that the original claim has been revised with corrected information. Claims marked "Rebill" may be denied as a duplicate.

We frequently receive perio charting and other documentation that we are not able to link with the appropriate claim because the information provided with the perio charting does not include sufficient patient information. In many instances, we cannot identify the patient or the provider of service; as a result, we cannot contact your office for more information. Please clearly mark all additional claim documentation with the dentist/denturist’s name, patient’s name, member’s Social Security number and the patient’s date of birth to ensure timely processing of these claims.

How to expedite claims for major services

Major services such as crowns, onlays, and buildups require submission of pre-treatment x-rays for timely processing.

If you are submitting your claims electronically, please indicate in the comment section of the claim, "X-rays being mailed." If we receive your x-rays within 14 days, along with the appropriate patient and dentist information, we can match up the claim and x-rays. However, if we receive the x-ray more than 14 days after your submitted electronic claim, the claim will automatically be denied. Your office will have to resubmit the claim, which is an additional expense.

Please do not submit the procedure code 00110 for an examination. The ADA deleted this code in the CDT-3 list of codes that were effective January 1, 2000. Instead, please use D0150, comprehensive oral evaluation, for a new patient examination. Refer to the ADA’s CDT-3 manual for a complete description of the procedure code.

Difficult prophylaxis

The ADA has not created a procedure code to support a difficult prophylaxis. Do not bill with 01130, as this is not a valid ADA-approved code. Using 01130 will result in the procedure being denied as not a valid ADA code.

Difficult prophylaxis is not a covered benefit under Regence BlueShield dental products, and any charges over and above the standard prophy are the patient’s responsibility.

If a difficult prophylaxis is completed on the same day, you may split your charge into two lines and bill your normal charge for a standard prophylaxis on the first line with the code D1110, and the balance of your charge on the second line with a description of what the charge is for (i.e., additional charge for difficult prophy) with a miscellaneous procedure code such as D1999. Regence BlueShield will pay the standard prophy, and the balance under the miscellaneous code will be the patient’s responsibility.

If a prophylaxis covers two different dates, you may bill both as D1110. If the patient has not yet exhausted the prophylaxis benefit for the year, both services will be paid. However, if the patient needs an additional prophylaxis later in the same calendar year, that prophy would exceed a standard contract’s yearly limitation, and charges will be the patient’s responsibility.