August 2002: Dental Provisions #19

Claims Submission Tips

X-rays

• Do not code full mouth x-rays including 10 or more periapical x-rays and bitewing x-rays separately. Instead, please use the ADA procedure code of D0210.
• Appropriate pre-treatment x-rays are required for crowns and buildups or boney impacted extractions.

Please remember:

• To include the patient's name.
• To indicate the date the x-ray was taken.
• To provide the dentist's name and address.
• To make sure that duplicate x-rays indicate "right" and "left."
• That full-mouth x-rays are mounted.
• To send only x-rays that are applicable to the treatment plan being submitted.

If you have questions about when to send x-rays and/or charting, please refer to the "Required Attachment Documentation" published in the February 2002 issue of Dental Provisions or contact your dental relations representative for a copy of the attachment criteria.

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 benefits (for example, when a benefit provides for replacement every seven calendar years). Do not list "over 7 years" in place of the actual date of prior placement; doing so will lead to the claim being denied or returned for more information.

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

Claim appeals or reconsiderations
Claims appeals must be clearly noted as "appeal" or "reconsideration." Please do not submit an appeal electronically as this will cause it to be processed as a regular claim and then denied as a duplicate.

ADA procedure codes
To ensure accurate processing, make sure to report the correct code when billing for procedures (i.e., use the primary restoration codes for services on primary teeth and the permanent restoration codes for services on permanent teeth). Using the wrong codes could result in an incorrect payment amount, requiring your office to call for an adjustment to the claim.
Whenever a miscellaneous ADA procedure code is submitted, whether electronically or on paper, please be sure to include a description of the treatment performed.

Quadrants, tooth numbers and surfaces
Make sure to list the tooth numbers, surfaces restored and/or quadrants involved in the treatment being submitted for payment. Claims without this information are delayed or returned until the information is obtained.

One x-ray/two separate services for claims or pre-treatment estimate
Please use one claim/estimate form for services that require the same x-ray (such as a buildup and a crown on the same tooth). Doing so prevents you from having to send the same x-ray twice.

Please do not submit a claim and a pre-treatment estimate for the same service at the same time. If you include an x-ray, please staple it to the claim.

Claim message codes N34, P30 or W66
When you call our provider customer service area, you can now obtain more information on the following message codes by pressing 2 to be transferred to a dental analyst:

• N34 Procedure not covered following dental consultant's review.
• P30 Amalgam or composite filling allowance provided per dental consultant's review.
• W66 Allowance based on dental consultant's review.

Note: Do not press option 2 for standard benefits, claim status or eligibility inquiries.

Back to Dental Provisions #19