|
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. |
