The following is an item-by-item description of the questions appearing on the reverse side of the Coastal medical claim form. All questions should be answered as completely as possible to facilitate prompt benefit administration and to reduce follow-up questions. Note: The term "employee/retiree" used on this form refers to the plan participant (e.g., employee, retiree, union member, associate, surviving spouse, or those eligible under continuation of coverage).

ITEM NO. INSTRUCTIONS

1. Employee/retiree member identification number: Enter the employee/retiree's

identification number.

2. Patient name: Enter the patient's name (last name, first name, middle initial).

3. Patient birth date and sex: Enter the patient's birthdate (month, day, year) and gender.

4. Employee/retiree name: Enter the employee/retiree's name (last name, first name,

middle initial).

5. Patient address: Enter the patient's address (house number and street, city, state, zip

code) and telephone number with area code.

6. Patient relationship to person in 4: Indicate the patient's relationship to the person

listed in item 4. If the employee/retiree is the patient, check "Self". If the patient is a

spouse or child, check "Spouse" or "Child". If the patient is neither self, spouse, or child,

check "Other".

7. Employee/retiree address: Enter the employee/retiree's address (house number, street,

city, state, zip code) and telephone number with area code.

8. Patient status: indicate the patient's status (Single, Married, or Other, and Employed,

Full-Time Student, or Part-Time student) as appropriate.

9. If there is other coverage, name and policyholder: If the patient has other health

coverage, check yes, and go to the box underneath, 9a., following the instructions as

listed below.

9a. Name of the policyholder in item 9: Enter the name of the person carrying the other

coverage.

9b. Identification number of policyholder in item 9: Enter the identification number of the

person carrying the other coverage.

9c. Name of Group Medical Plan for policyholder in item 9: Enter the name of the other

plan or program for the policyholder carrying the other coverage, whose name appears in

box 9a.

10. Is patient's condition related to: Check each of the boxes marked "Yes" or "No" as

appropriate under a., b., and c., and if an auto accident write the two-letter abbreviation

for the state where the accident occurred (i.e., CA).

11. Employee/retiree group number: This has already been supplied; do not write in this

box.

12. Employer name: This has already been supplied; do not write in this box.

13. Employee/retiree or authorized person's signature: This is the "assignment of

benefits." Sign here ONLY if you want benefits paid directly to the provider of services. If you want benefits paid directly to the member, then leave this item unsigned.

14. Patient or authorized person's signature: Signature of patient or their authorized

representative for the release of information.

The dental claim 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. Please note:

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.

 

Specific Dental Claim Form Instructions:

1. EPSDT / Title XIX --Mark box if patient is covered by state Medicaid's Early and Periodic Screening, Diagnosis and Treatment program for persons under age 21.

2. Enter number provided by the payer when submitting a claim for services that have been predetermined or preauthorized.

4 - 11. Leave blank if no other coverage.

8. The subscriber's Social Security Number (SSN) or other identifier (ID#) assigned by the payer.

15. The subscriber's Social Security Number (SSN) or other identifier (ID#) assigned by the payer.

16. Subscriber's or employer group's Plan or Policy Number. May also be known as the Certificate Number. (Not the subscriber's identification number.)

19 - 23. Complete only if the patient is not the Primary Subscriber (i.e., "Self" not checked in Item 18).

19. Check "FTS" if patient is a dependent and full-time student; "PTS" if a part-time student. Otherwise, leave blank.

23. Enter if dentist's office assigns a unique number to identify the patient that is not the same as the Subscriber Identifier number assigned by the payer (e.g., Chart #).

25. 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. 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. 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. 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. Use appropriate dental procedure code from current version of Code on Dental Procedures and Nomenclature.

31. Dentist's full fee for the dental procedure reported.

32. 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.

33. Total of all fees listed on the claim form.

34. Report missing teeth on each claim submission.

35. Use "Remarks" space for additional information such as 'reports' for '999' codes or multiple supernumerary teeth.

[NOTE: Steps 25-35 may not be needed if you supply an itemized bill from your dentist.]

36. Patient Signature: The patient is defined as an individual who has established a professional relationship with the dentist for the delivery of dental health care. For matters relating to communication of information and consent, this term includes the patient's parent, caretaker, guardian, or other individual as appropriate under state law and the circumstances of the case.

37. Subscriber Signature: Necessary when the patient/insured and dentist wish to have benefits paid directly to the provider. This is an authorization of payment. It does not create a contractual relationship between the dentist and the payer.

38. ECF is the acronym for Extended Care Facility (e.g., nursing home).

48-52. Leave blank if dentist or dental entity is not submitting claim on behalf of the patient or insured/subscriber.

48. 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.

49. Identifier assigned to Billing Dentist of Dental Entity other than the SSN or TIN. Necessary when assigned by carrier receiving the claim

50. Refers to the license number of the billing dentist. This may differ from that of the treating (rendering) dentist that appears in the treating dentist's signature block.

52. The Internal Revenue Service requires that either the Social Security Number (SSN) or Tax Identification Number (TIN) of the billing dentist or dental entity be supplied only if the provider accepts payment directly from the third-party payer. When the payment is being accepted directly, report the: 1) SSN if the billing dentist in unincorporated; 2) Corporation TIN if the billing dentist is incorporated; or 3) Entity TIN when the billing entity is a group practice or clinic.

53. 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.

56. Full address, including city, state and zip code, where treatment performed by treating (rendering) dentist.

58. 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