January 2002: Dental Provisions #18

CLAIMS PROCESSING TIPS

TMD services
When submitting claims for procedures related to TMD, please indicate the diagnosis code of 524.6 under either the medical or dental plans. The diagnosis code can be listed in the comment section of the electronic or paper claim. This will eliminate possible delays or denials and expedite processing. The diagnosis code helps us identify this claim type and avoid unnecessary delays.

Partial dentures
When placing a partial denture, please indicate the tooth numbers being replaced. We need this information for accurate records.

Replacement prosthesis
To eliminate delays when billing for a replacement prosthesis, please provide a brief narrative and the month and year of the prior prosthesis placement. We need this information when verifying whether the replacement falls within the limits of the patient's benefit (for example, when a benefit provides for replacement every seven calendar years). Do not list "over 7 years" in place of the actual date; doing so will lead to the claim being denied or returned for more information.

X-rays required
Pre-treatment x-rays are required for crowns, buildups, bridges (preferably bitewing x-rays) and boney impacted extractions. Certain periodontal and endodontic procedures also require that a pre-treatment x-ray be submitted with the initial claim. Please refer to the "Required Attachment Documentation" pull-out section included in this newsletter for a complete list. Also, include the patient's name, date of x-ray, dentist's name and address and indicate "right" or "left" on duplicate x-rays.

Procedure codes
Please do not submit claims with codes that were deleted by ADA effective January 1, 2000. Examples of deleted codes are 00110 and 00130. These codes are no longer valid and may be denied as "invalid procedure code." Please refer to the ADA CDT-3 manual, which reflects the current valid procedure codes.

If you do not have a CDT-3 manual, you can buy one through the ADA or at some of the local major bookstores.

Multiple office locations
If your dentist works at multiple office locations, please indicate on each claim form the actual office location where services were rendered. Doing so will help us send the payments to the correct location.

Resubmittals
We are receiving an unusually high number of resubmitted claims. Before resubmitting claims, please contact our Provider Customer Service Department at 1-800-848-5424 to check on a claim's status.

Electronic claims
To prevent delays and claims returned to your office, please provide tooth numbers, tooth surfaces and quadrants on your electronic claims. If you submit a miscellaneous procedure code, please make sure to include a description of the procedure that will allow us to process the claim the first time we review it. In addition, x-rays should be submitted if the procedure performed requires them for processing.

Name of treating dental provider
Please provide the name of the treating dental provider-not just the clinic name-on both electronic and paper claims. When multiple providers work at the same location under the same tax identification number, we may have to delay or return claims that are submitted without the treating provider's name.

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