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    EXC-MBR-MDM-EMP-BKR-Dental Claim Form

    Uploaded by

    nicholas beehner
    The dental claim form collects information about the patient, insurance provider, and dental services received in order to submit a claim for reimbursement. It requests identifying information for both the patient and their insurance policy, as well as details of the dental treatment including dates of service, procedures performed, diagnoses, fees, and treating dentist. The patient and dentist must both sign to authorize submission and payment of the dental claim.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    EXC-MBR-MDM-EMP-BKR-Dental Claim Form

    Uploaded by

    nicholas beehner
    42 views2 pages
    The dental claim form collects information about the patient, insurance provider, and dental services received in order to submit a claim for reimbursement. It requests identifying information for both the patient and their insurance policy, as well as details of the dental treatment including dates of service, procedures performed, diagnoses, fees, and treating dentist. The patient and dentist must both sign to authorize submission and payment of the dental claim.

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    EXC-MBR-MDM-EMP-BKR-Dental Claim Form

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    The dental claim form collects information about the patient, insurance provider, and dental services received in order to submit a claim for reimbursement. It requests identifying information for both the patient and their insurance policy, as well as details of the dental treatment including dates of service, procedures performed, diagnoses, fees, and treating dentist. The patient and dentist must both sign to authorize submission and payment of the dental claim.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    42 views2 pages

    EXC-MBR-MDM-EMP-BKR-Dental Claim Form

    Uploaded by

    nicholas beehner
    The dental claim form collects information about the patient, insurance provider, and dental services received in order to submit a claim for reimbursement. It requests identifying information for both the patient and their insurance policy, as well as details of the dental treatment including dates of service, procedures performed, diagnoses, fees, and treating dentist. The patient and dentist must both sign to authorize submission and payment of the dental claim.

    Copyright:

    © All Rights Reserved
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    165 Court Street

    Customer Submitted Rochester NY 14647


    Dental Claim Form
    A nonprofit independent
    licensee of the BlueCross Mail Completed Forms To: Excellus BlueCross BlueShield
    BlueShield Association PO Box 21146
    Eagan, MN 55121
    HEADER INFORMATION
    POLICYHOLDER/SUBSCRIBER INFORMATION (For Insurance Company Named in #3)
    1. Type of Transaction (Mark all applicable boxes)
     Statement of Actual Services 
    Request for Predetermination/Preauthorization 12. Policyholder/Subscriber Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code
     EPSDT/Title XIX
    2. Predetermination/Preauthorization Number

    INSURANCE COMPANY/DENTAL BENEFIT PLAN INFORMATION


    3. Company/Plan Name, Address, City, State, Zip Code 13. Date of Birth (MM/DD/CCYY) 14. Gender 15. Policyholder/Subscriber ID
     M F

    16. Plan/Group Number 17. Employer Name

    OTHER COVERAGE
    4. Dental?    Medical?  (If both, complete 5 – 11 for dental only)
    PATIENT INFORMATION
    18. Relationship to Policyholder/Subscriber in #12 Above
    5. Name of Policyholder/Subscriber in #4 (Last, First, Middle Initial, Suffix) 19. Reserved for Future
    Self Spouse 
    Dependent Child 
    Other Use

    20. Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code
    6. Date of Birth (MM/DD/CCYY) 7. Gender 8. Policyholder/Subscriber ID
     M F

    9. Plan/Group Number 10. Patient's Relationship to Person Named in #5


      Self  Spouse  Dependent 
    Other

    11. Other Insurance Company/Dental Benefit Plan Name, Address, City, State, Zip Code
    21. Date of Birth (MM/DD/CCYY) 22. Gender 23. Patient ID/Account # (Assigned by
     M F Dentist)

    RECORD OF SERVICES PROVIDED


    24. Date of 25. Area 26. Tooth 27. Tooth 28. Tooth 29. 29a. Diag. 29b. 30. Description 31. Fee
    Service of Oral System Number(s) Surface Procedure Pointer Qty
    (MM/DD/CCYY) Cavity or Letter(s) Code
    1
    2
    3
    4
    5
    6
    7
    8
    9
    10
    33. Missing Tooth Information Place an “X” on each missing tooth) 34. Diagnosis Code List Qualifier (ICD-9 = B; ICD10 = A8) 31a. Other
    Fee(s)
    1 2 3 4 5 6 7 8 9 10 11 12 13 14 16 16 34a. Diagnosis Code(s) A _______________ C ________________
    (Primary diagnosis in “A”) B ________________ D ________________
    32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 32. Total Fee
    35. Remarks

    AUTHORIZATIONS ANCILLARY CLAIM/TREATMENT INFORMATION


    36. I have been informed of the treatment plan and associated fees. I agree to be responsible for all 38. Place of Treatment ( e.g. 11=office; 22=O/P Hospital) 39. Enclosures (Y or N)
    charges for dental services and materials not paid by my dental benefit plan, unless prohibited by
    law, or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all (Use “Place of Service Codes for Professional Claims”) 
    or a portion of such charges. To the extent permitted by law, I consent to your use and disclosure of
    my protected health information to carry out payment activities in connection with this claim. 40. Is treatment for Orthodontics? 41. Date Appliance Placed (MM/DD/CCYY)

    X _____________________________________________________________________________
     No (Skip 41-42) 
    Yes (Complete 41-42)
    Patient/Guardian signature Date 42. Months of Treatment 43. Replacement of Prosthesis? 44. Date Prior Placement (MM/DD/CCYY)
    Remaining
    37. I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to  No  Yes (Complete 44)
    the below named dentist or dental entity.
    45. Treatment Resulting from
    X _____________________________________________________________________________  Occupational illness/injury  Auto accident  Other accident
    Patient/Guardian signature Date 46. Date of Accident (MM/DD/CCYY) 47. Auto Accident State
    BILLING DENTIST OR DENTAL ENTITY (Leave blank if dentist or dental entity is not submitting
    claim on behalf of the patient or insured/subscriber.) TREATING DENTIST AND TREATMENT LOCATION INFORMATION

    53. I hereby certify that the procedures as indicated by date have been completed.
    48. Name, Address, City, State, Zip Code
    X ______________________________________________________________________________
    Signed (Treating Dentist) Date

    54. NPI 55. License Number

    56. Address, City, State, Zip Code 56A. Provider Specialty Code

    49. NPI 50. License Number 51. SSN or TIN


    57. Phone 58. Additional
    52. Phone 52A. Additional Provider ID Number ( ) - Provider ID
    Number ( ) -

    Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information, or conceals information
    concerning any fact material thereto, for the purpose of misleading, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed $5,000
    and the stated value of the claim for each violation.
    I certify that the procedures as indicated by date, have been completed, personally supervised or rendered by me the attending dentist, that the fees submitted are actual fees I have charged and intended
    to collect.
    Dentist signature: Date:

    For assistance in filing your claim, please read the instructions on the back.
    MSA-56 • 4/19
    GENERAL INSTRUCTIONS
    A. The form is designed so that the name and address (Item 3) of the third-party payer receiving the claim (insurance company/dental benefit
    plan) is visible in a standard #10 window envelope.
    B. In the upper-right of the form, a blank space is provided for the convenience of the payer or insurance company, to allow the assignment of
    a claim or control number.
    C. All Items in the form must be completed unless it is noted on the form or in the following instructions that completion is not required.
    D. When a name and address field is required, the full name of an individual or a full business name, address and zip code must be entered.
    E. All dates must include the four-digit year.
    F. If the number of procedures reported exceeds the number of lines available on one claim form, the remaining procedures must be listed on
    a separate, fully completed claim form.

    COORDINATION OF BENEFITS (COB)


    When a claim is being submitted to the secondary payer, complete the form in its entirety and attach the primary payer's Explanation of Benefits
    (EOB) showing the amount paid by the primary payer.

    NATIONAL PROVIDER IDENTIFIER (NPI)


    49 and 54 NPI (National Provider Indentifier): This is an identifier assigned by the Federal government to all providers considered to be HlPAA
    covered entities. An NPI is unique to an individual dentist (Type 1 NPI) or dental entity (Type 2 NPI), and has no intrinsic meaning.
    Additional information on NPI and enumeration can be obtained from the ADA's Internet Web Site: www.ada.org/goto/npi

    ADDITIONAL PROVIDER IDENTIFIER


    52A and 58 Additional Provider ID: This is an identifier assigned to the billing dentist or dental entity other than a Social Security Number (SSN)
    or Tax Identification Number (TIN). It is not the provider's NPI. The additional identifier is sometimes referred to as a Legacy
    Identifier (LID). LIDs may not be unique as they are assigned by different entities (e.g., third-party payer; Federal government). Some
    Legacy IDs have an intrinsic meaning.

    PROVIDER SPECIALTY CODES


    56A Provider Specialty Code: Enter the code that indicates the type of dental professional who delivered the treatment. Available codes
    describing treating dentists are listed below. The general code listed as 'Dentist' may be used instead of any other dental practitioner
    code.

    Category / Description Code Code


    Dentist
    A dentist is a person qualified by a doctorate in dental surgery
    122300000X
    (D.D.S) or dental medicine (D.M.D.) licensed by the state to
    practice dentistry, and practicing within the scope of that license.
    General Practice 1223G0001X
    Dental Specialty (see following list) Various
    Dental Public Health 1223D000IX
    Endodontics 1223E0200X
    Orthodontics 1223X0400X
    Pediatric Dentistry 1223P022IX
    Periodontics 1223P0300X
    Prosthodontics 1223P0700X
    Oral & Maxillofacial Pathology 1223P0106X
    Oral & Maxillofacial Radiology 1223D0008X
    Oral & Maxillofacial Surgery 1223S0112X

    Dental provider taxonomy codes listed above are a subset of the full code set that is posted at:
    www.wpc-edi.com/codes/taxonomy

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