Service Line Details Service Line DetailsEach service line on a Dental Claim will have information available in addition to what is displayed in summary on the main page. This information is accessed by clicking the More icon on the main Service Line(s) page.
The top of the screen will display information on what service line more button you are on. This includes, Line Number, Line Item CTL #, DOS, ADA Code, Proc Count, Oral Cavity Area, Tooth Num, Tooth Surface Codes and Amt Chrg that was enter on the service line.
Currently, the dx pointer is not used for dental.
Tooth Number/Tooth Surface Codes: A single Tooth Number and associated Surface Code may be entered/viewed on the main Service Line Summary page; you may add/view a maximum of 32 Tooth Number/Surface Code combinations, however a Tooth Number may not be repeated on an individual Service Line. If a Tooth Number or Surface Information was entered on the main Service Line page, the values will default to the first corresponding field on this page.
Place of Service: A two-digit code representing the Place of Service Code where the particular Service Line procedure was rendered. Enter or select the desired code from the provided list of valid values. If entered, this value should be different than the value entered on the Dental Claim Information tab.
Prosthesis, Crown, or Inlay Code: If this procedure involved the placement of a prosthetic, select the proper button to indicate if this was an 'Initial Placement' or a 'Replacement'. If this is a 'Replacement', the Prior Placement Date is required.
Prior Placement Date: Choose whether the placement date is "Actual Prior Placement Date" or "Estimated" date. The Date on which the prosthetic was previously placed must be entered if the "Prosthesis, Crown, or Inlay Code" indicates that this is a 'Replacement' procedure. 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 Banding Date: The date on which the Orthodontic Banding occurred. 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.
Replacement Date: Date on which the orthodontic appliance was replaced. 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.
Prior Authorization Number: If Prior Authorization has been received for the procedures associated with this Service Line and the number is different from that entered on the Dental Claim Information tab, enter the number in the field. Prior Authorization numbers are assigned by the payer to authorize a service prior to its being performed. This number is specific to NY Medicaid.
Treatment Start Date: Enter the date the treatment started.
Treatment Completion Date: Enter the date the treatment completed.
Procedure Code Description: Use to provide additional information about the procedures on the Service Line.
Other Payer Name: The Payer Name selected must match one of those entered on the Other Payer tab. All subsequent data entered applies to the Adjudication for this Service Line and Payer combination.
Service Line Paid Amount: The dollar amount paid towards this Service Line by this Payer.
Paid ADA Code: This is the ADA Procedure code processed by the payer.
Paid Service Unit Count: The Units of Service paid by the other payer.
Bundled Line Number: If applicable, enter the number of the line bundled or unbundled by the other payer.
Date Claim Paid: Service adjudication or payment date must be entered. The date may not be greater than the current date. The format 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.
Remaining Patient Liability: This is the amount the provider believes is due and owing after the Other Payer’s adjudication.
Claim Adjustment Group: Enter the Group Code as received from the other payer.
Reason Code: Enter the Claim Adjustment Reason Code as received from the other payer. The Claim Adjustment Group/Reason Code combination may not be entered more than once. If an Adjustment Amount or Adjustment Quantity is entered, a Reason Code is required.
Adjustment Amount: Enter the Adjustment Amount as received from the other payer. An Adjustment Amount is required when a Reason Code is entered.
Adjustment Quantity: Enter the Quantity Adjusted as received from the other payer.
If Other Payers have been included on the claim and they have adjudicated this line or you need to maintain the adjudication details, you may view/maintain the individual Line Adjudication Information or view a summary of all adjudication information for this line.
Click here for the controls located at the bottom of the page.
