ELEMENT |
REQUIRED |
DESCRIPTION |
1. Type of transaction |
YES |
|
2. Predetermination / Preauthorization Number |
YES |
Enter the Authorization # for service. All Claims
require an Authorization # for processing. It is
the referring custodial facility's responsibility to
provide this information to the provider. |
3. Primary payer information |
YES |
Use address already entered on sheet: Div. of
Immigration Health Svcs, 1220 L. Street N.W., Suite
500, PMB 468, Washington, DC 20005 |
4 - 11. Leave blank if no other coverage |
NO |
|
12. Primary subscriber information |
YES |
Enter the detention facility’s address where the
recipient resides. If recipient in custody of
Border Patrol, enter the Border Patrol Station of
the Border Patrol Officer(s). Do not use the
detainee's home address. |
13. DOB |
YES |
|
14. Gender |
YES |
|
15. Subscriber Identifier (SSN or ID#) |
YES |
All claims require one of the following recipient
numbers in order for processing. Enter the
recipient’s Alien Identification Number. If not
available, enter recipient's Fingerprint ID Number.
If not available, enter recipient's Event Number. Do
not enter any other numbers or letters. It is the
referring custodial facility's responsibility to
provide this information to the provider. |
16-23 |
NO |
|
24. Procedure Date |
YES |
|
25. Area of Oral Cavity |
YES |
Designate tooth number or letter when procedure code
directly involves a tooth. Use area of the oral
cavity code set from ANSI/ADA/ISO Specification No.
3950 'Designation System for Teeth and Areas of the
Oral Cavity'. |
26. Tooth System |
YES |
Enter applicable ANSI ASC X12 code list qualifier:
Use "JP"
when designating teeth using the ADA's
Universal/National Tooth Designation System. Use "JO"
when using the ANSI/ADA/ISO Specification No. 3950. |
27. Tooth Number(s) or Letter(s) |
YES |
Designate tooth number when procedure code reported
directly involves a tooth. If a range of teeth is
being reported use a hyphen ('-') to separate the
first and last tooth in the range. Commas are used
to separate individual tooth numbers or ranges
applicable to the procedure code reported. |
28. Tooth Surface |
YES |
Designate tooth surface(s) when procedure code
reported directly involves one or more tooth
surfaces. Enter up to five of the following codes,
without spaces: B
= Buccal;
D =
Distal; F
= Facial;
L =
Lingual; M
= Mesial; and
O =
Occlusal. |
29 Procedure Code |
YES |
Use appropriate dental procedure code from current
version of Code on Dental
Procedures and Nomenclature. |
30. Description |
YES |
Dentist’s full fee for the dental procedure
reported. |
31 Fee |
YES |
Used when other fees applicable to dental services
provided must be recorded. Such fees include state
taxes, where applicable, and other fees imposed by
regulatory bodies. |
32. Other Fee(s) |
YES |
|
33. Total Fee |
YES |
Total of all fees listed on the claim form. |
34. Place an ‘X’ on each missing tooth |
YES |
Report missing teeth on each claim submission. |
35. Remarks |
YES |
Use "Remarks" space for additional information such
as 'reports' for '999' codes or multiple
supernumerary teeth. |
36. Patient Signature |
NO |
|
37. Subscriber signature |
NO |
|
38. Place of treatment |
YES |
ECF is the acronym for Extended
Care
Facility
(e.g., nursing home). |
39. Enclosures |
NO |
|
40-44. Orthodontics treatment |
NO |
|
45-47 |
NO |
|
48-52 Dentist information |
YES |
The individual dentist's name or the name of the
group practice/corporation responsible for billing
and other pertinent information. This may differ
from the actual treating dentist's name. This is the
information that should appear on any payments or
correspondence that will be remitted to the billing
dentist. |
53. Provider signature |
YES |
The treating, or rendering, dentist's signature and
date the claim form was signed. Dentists should be
aware that they have ethical and legal obligations
to refund fees for services that are paid in advance
but not completed. |
54. Provider Id |
YES |
|
55. License Number |
YES |
|
56 Provider Address |
YES |
Full address, including city, state and zip code,
where treatment performed by treating (rendering)
dentist. |
57. Phone number |
YES |
|
58. Treating provider specialty |
YES |
Enter the code that indicates the type of dental
professional rendering the service from the 'Dental
Service Providers' section of the
Healthcare Providers Taxonomy
code list. The current
list is posted at: http://www.wpc-edi.com/codes/codes.asp.
The available taxonomy codes, as of the first
printing of this claim form, follow printed in
boldface. |