Dental Claim Information
Dental Claim InformationInformation specific to a Dental Claim is entered on this tab. A portion of the data elements is unique to this claim type and will not be seen on the tabs when entering other types of claims. The page is visually separated into sections using different shading. Each section/field is discussed below , click on the section name to view the details to the fields in that section .
Place of Service: Enter the code from the CMS Place of Service code list that is most appropriate for the service location type. Required for all Dental claims.
Assignment of Benefits? Select 'Yes' if the insured or authorized person authorizes benefits to be assigned to the provider. Select 'No' if benefits have not been assigned to the provider. Required for all dental claims. Defaults to 'Yes'.
Release of Information? Enter or select the code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations. Required for all dental claims. Defaults to 'Y'.
Accept Assignment? Enter or select the appropriate value from the provided list to indicate whether the provider has a participation agreement with the payer. This field is required on all claims.
Patient Paid Amount: The sum of all amounts paid on the claim by the patient or his/her representative, if any.
Prior Authorization Number: If Prior Authorization has been received for the services associated with this claim, enter the prior approval number in the field. Prior Authorization numbers are assigned by the payer to authorize a service prior to its being performed.
While not enforced with validation in ePACES, the Service Date information entered should be inclusive of all service dates reported at the line level.
From Date: The first date on which the procedures covered by this claim were rendered. The date may not be greater than the current date. The format for the date is: MM/DD/YYYY and may either be entered in the field or selected from the calendar available by pressing the button to the right of the field.
To Date : The last date on which the procedures covered by this claim were rendered. The date may not be greater than the current date and must be equal to or greater than the From Date. The format for the date is: MM/DD/YYYY and may either be entered in the field or selected from the calendar available by pressing the button to the right of the field.
Related Causes: You may select up to two related causes for this claim. If one or more of the options applies to the situation, mark the appropriate check box(es) and enter the Accident Date. If Auto Accident is selected as a Related Cause, enter the state and country in which the accident occurred. 'NY' and 'USA' are the default values.
Accident Date: If either the Other Accident or Auto Accident boxes are checked, the date of the accident must be entered. When the Employment box is checked and the services are caused by an accident, enter the accident date. The date may not be greater than the current date. The format of the date is: MM/DD/YYYY and may either be entered in the field or selected from the calendar available by pressing the button to the right of the field.
Orthodontic Treatment Months: Enter the total months, whole or partial, of orthodontic treatment.
Orthodontic Treatment Months Remaining: Enter the number of months, whole or partial, of orthodontic treatment remaining. If entered, this value must be less than the Orthodontic Treatment Months Count entered above.
Orthodontic Treatment Indicator: Click on the box if there are Orthodontic services rendered, but no Monthly information is available.
Orthodontic Banding Date: A maximum of 5 Orthodontic Banding Dates may be entered. The format of the date is: MM/DD/YYYY and may either be entered in the field or selected from the calendar available by pressing the button to the right of the field.
Tooth Number/Tooth Status: Enter or select the number and status of each tooth missing tooth or tooth to be extracted. If a tooth number is selected, an associated status must also be selected. While up to 35 tooth number/status combinations may be entered on a single claim, a tooth number may not be duplicated. If more than six values need to be entered, click Enter More Tooth Numbers... and additional lines will be displayed.
Group Provider Number: If there is a Group Provider which is different than the Billing Entity for this claim, enter the 10-digit National Provider ID and click Go. This will retrieve the Provider's contact information from the database and display it.
Click here for the controls located at the bottom of the page or continue to the Physician Information tab.
