Division of Immigration Health Services
Dental Claim Form


Dental Claim Form General Instructions:

General Instructions:
The form is designed so that the Primary Payer's name and address (Item 3) is visible in a standard #10 window envelope. Please fold the form using the 'tick-marks' printed in the left and right margins. The upper-right blank space is provided for insertion of the third-party payer's claim or control number.

a) All data elements are required unless noted to the contrary on the face of the form, or in the Data Element Specific Instructions that follow.
b) When a name and address field is required, the full entity or individual name, address and zip code must be entered (i.e., Items 3, 11, 12, 20 and 48).
c) All dates must include the four-digit year (i.e., Items 6, 13, 21, 24, 36, 37, 41, 44, and 53.
d) If the number of procedures being reported exceeds the number of lines available on one claim form the remaining procedures must be listed on a _
separate, fully completed claim form. Both claim forms are submitted to the third-party payer.
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.
122300000X Dentist -- A dentist is a person qualified by a doctorate in dental surgery (D.D.S.) or dental medicine (D.M.D.) licensed by the state to practice dentistry, and practicing within the scope of that license.
Many dentists are general practitioners who handle a wide variety of dental needs.
1223G0001X General Practice
Other dentists practice in one of nine specialty areas recognized by the American Dental Association:
1223D0001X Dental Public Health
1223P0221X Pediatric Dentistry
1223E0200X Endodontics (Pedodontics)
1223P0106X Oral & Maxillofacial Pathology
1223P0300X Periodontics
1223D0008X Oral and Maxillofacial Radiology
1223P0700X Prosthodontics
1223S0112X Oral & Maxillofacial Surgery
1223X0400X
Orthodontics
Copyright 2003 All Rights Reserved