Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MassHealth Dental Bulletin 35 June 2006 TO: Dental Providers Participating in MassHealth FROM: Beth Waldman, Medicaid Director RE: American Dental Association (ADA) Claim Form for Paper MassHealth Claims, Changes to Remittance Advices for Paper Claims, and Billing Instructions Use of ADA Claim Form by July 1, 2006 Effective July 1, 2006, MassHealth will accept only the industry standard ADA Dental Claim Form, either the 2002 or 2004 version, for all paper submissions for dental services. Information about this transition was also included in Dental Bulletin 34, dated March 2006. The MassHealth Dental Program completed the pilot phase with selected providers for accepting the ADA Claim Form. Providers were subsequently notified beginning April 18, 2006, through messages printed on paper remittance advices, the MassHealth provider newsletter Update, the MassHealth Web site, and other forms of communication, that they could begin submitting claims using the ADA Claim Form. During the transition period, MassHealth will accept and process claims for dental services on either the MassHealth claim form no. 11 or the ADA Dental Claim Form versions 2002 and 2004. However, we will not accept any MassHealth no. 11 claim forms after June 30, 2006. Electronic Claims There is no change for electronic claim submissions. We will continue to accept claims for dental services electronically in the HIPAA-compliant 837-Dental format, including Coordination of Benefits claims. We also offer free HIPAA-compliant software to providers who want to submit their claims electronically. Billing Requirements The ADA Claim Form completion requirements for MassHealth are primarily the same as those for other payers. However, there are some requirements that are specific to MassHealth. In November 2005, we met with dental software vendors and billing agents and reviewed these requirements. These unique requirements are listed below. * Adjustment and Resubmittal Claims. Information for MassHealth adjustment and resubmittal claims must be entered in Field 35, “Remarks,” of the ADA Claim Form. For MassHealth resubmittals that require a transaction control number (see All Provider Bulletin 123, dated May 2003), enter “R” followed by the 10-character transaction control number (TCN) assigned to the original claim. For MassHealth adjustments, enter “A” followed by the 10-character TCN assigned to the most recently paid claim. Do not enter any other information in Field 35. * Request for Predetermination/Preauthorization. Do not enter any information in Field 1b, “Request for Predetermination/ Preauthorization.” MassHealth does not use this form for prior-authorization requests. For information about requesting prior authorization, see Part 2 in Subchapter 5 of the Dental Manual and applicable sections of the MassHealth regulations in Subchapter 4 of the Dental Manual. * Tooth Quadrants. Tooth quadrant codes for MassHealth are limited to the following codes: 10, 20, 30, and 40. These are HIPAA-compliant indicators for quadrants. * Billing Agent Number. Use Field 16, "Plan/Group Number," to report the billing agent number, if applicable. * Other Insurance. If the member has other insurance, please follow these additional instructions. 1. Attach to the completed claim form an explanation of benefits (EOB) from the other insurer. 2. Ensure that the payments on the EOB are itemized. 3. Make sure that the payment line on the EOB corresponds to the claim line on the ADA form that you are submitting to MassHealth. This may require you to annotate the EOB with a number that corresponds to the claim line on the ADA Claim Form. 4. If the service codes on the EOB differ from the service codes on the claim, annotate on the EOB how they differ. 5. Check the “Yes” box in Field 4 of the ADA Claim Form. Billing Instructions for ADA Claim Form, Versions 2002 and 2004 Please see the attached field-by-field instructions for completing the ADA Claim Form, versions 2002 and 2004, for MassHealth services. MassHealth created the attached document to supplement the ADA Claim Form 2002 and 2004 instructions. We are providing billing instructions at this time to allow all dental providers advance notice for assessing their software system capabilities and required changes to support submitting claims for dental services to MassHealth on the paper ADA Claim Form versions 2002 and 2004. The information in this document does not supersede MassHealth regulations. This document should be used in conjunction with the information found in the MassHealth Dental Manual. Please share this document with technical staff responsible for updating billing systems that will print paper ADA Claim Forms, versions 2002 and 2004, for submission to MassHealth. In addition, please share this information with your billing office to ensure that all required billing information is available for claim submission. Oral Surgeons Using Modifiers The ADA claim form, versi+ons 2002 and 2004, does not have a field for modifiers. Oral surgeons who need to use modifiers, such as 51 to indicate multiple procedures were performed or 80 to indicate that an assistant surgeon was required, must submit their claims containing modifiers in the HIPAA-compliant 837P format. Changes to Remittance Advices for Paper Claims We will now report only HIPAA-compliant tooth numbers and quadrants on the paper remittance advice. This means that providers continuing to submit claims on the no. 11 paper claim form during the transition period using MassHealth’s tooth number and quadrant codes, will see them crosswalked to the corresponding HIPAA-compliant codes on their paper RA. Providers submitting claims electronically or on the paper ADA Claim Form are required to enter HIPAA-compliant tooth numbers and quadrants when needed, and therefore will see the actual codes that they entered on their paper RAs. Questions If you have any questions about the information in this bulletin or would like more information about submitting your dental claims electronically, please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 6179888974. MassHealth Dental Bulletin 35 June 2006 Attachment Page 1 Instructions for Completing the ADA Claim Form, Versions 2002 and 2004, for MassHealth Field Description Instructions for Completion Directions Header Information     1 Dentist's Statement of Actual Services Always enter an X in this box for a MassHealth claim. REQUIRED FIELD   Request for Predetermination/Preauthorization MassHealth does not use this field.  For instructions on requesting prior authorization (PA), please refer to Subchapter 5 of the Dental Manual and MassHealth PA regulations in Subchapter 4 of the Dental Manual.  This form is not used to request PA.   LEAVE BLANK   EPSDT/Title XIX Enter an X in this box if the patient was referred for dental services as a result of an EPSDT medical screening. CONDITIONAL FIELD 2 Predetermination/Preauthorization Number If billing for a service for which PA is required, enter the six-digit PA number assigned by MassHealth. If there are multiple PA numbers, use a separate claim for each PA number. CONDITIONAL FIELD Primary Payer Information     3 Name, Address, City, State, Zip Code OPTIONAL FIELD Other Coverage     4 Other Dental or Medical Coverage? If the member has dental coverage in addition to MassHealth, * check Yes; * attach a copy of the explanation of benefits (EOB) from that insurer; and * itemize all payments on the EOB. REQUIRED FIELD Completing the ADA service lines in the same order as they appear on the EOB will expedite the claim entry process. If there is a different code or a different method used for payment by the other insurance, explain the conversion to MassHealth on the EOB. For example, if the primary payer uses D1201 to indicate a fluoride treatment and prophylaxis, report the distribution of payment as D1120 and D1203. If the member has other medical insurance, but it does not fully cover dental services (for example, orthodontic treatment), or if the member has no other insurance, check No and skip to Field 12. 5 Other Insured's Name OPTIONAL FIELD 6 Date of Birth OPTIONAL FIELD 7 Gender OPTIONAL FIELD 8 Subscriber Identifier (SSN or ID #) OPTIONAL FIELD 9 Plan/Group Number OPTIONAL FIELD 10 Patient's Relationship to Other Insured (Check applicable box.) OPTIONAL FIELD 11 Other Carrier Name, Address, City, State, Zip Code OPTIONAL FIELD Primary Insured Information   12 Name (Last, First, Middle Initial, Suffix) Address, City, State, Zip Code Enter the member’s complete name, address, and zip code. REQUIRED FIELD 13 Date of Birth (MM/DD/CCYY) Enter the member’s date of birth in one of the following three formats: MM/DD/CCYY, MM-DD-CCYY, or MMDDCCYY. REQUIRED FIELD 14 Gender Enter the member’s gender. REQUIRED FIELD 15 Subscriber Identifier (SSN or ID #) Enter the member's 10-character MassHealth identification number. REQUIRED FIELD 16 Plan/Group Number If this form is being prepared by a billing intermediary, enter the seven-digit number assigned to the billing agency by MassHealth** **Only those intermediaries who also submit electronic claims to MassHealth will have a number. OPTIONAL FIELD 17 Employer Name OPTIONAL FIELD Patient Information     18 Relationship to Primary Insured (Check applicable box) OPTIONAL FIELD 19 Student Status OPTIONAL FIELD 20 Name (Last, First, Middle Initial, Suffix) Address, City, State, Zip Code If completed, enter the information as it appears in Field 12. OPTIONAL FIELD 21 Date of Birth (MM/DD/CCYY) If completed, enter the information as it appears in Field 13. Enter the information in one of the following three formats: MM/DD/CCYY, MM-DD-CCYY, or MMDDCCYY. OPTIONAL FIELD 22 Gender If completed, enter the information as it appears in Field 14. OPTIONAL FIELD 23 Patient ID/ Account # (Assigned by Dentist) If the dental office has assigned a number to identify the patient, enter it here. OPTIONAL FIELD. Recommended to assist the provider in identifying patients when the MassHealth identification number may have been incorrect. The maximum number of characters for this field is 10. Record of Services Provided     24 Procedure Date Enter the date of service in one of the following three formats: MM/DD/CCYY, MM-DD-CCYY, or MMDDCCYY. REQUIRED FIELD 25 Area of Oral Cavity Report the quadrant of the oral cavity in this field. Acceptable quadrant values are listed below. 10 – Upper right quadrant 20 – Upper left quadrant 30 – Lower left quadrant 40 – Lower right quadrant CONDITIONAL FIELD 26 Tooth System OPTIONAL FIELD 27 Tooth Number(s) or Letter(s) Enter the permanent tooth number or primary tooth letter for tooth-specific services. Acceptable tooth numbers and letters are listed below. * 1 through 32 for permanent dentition * 51 through 82 for supernumerary permanent dentition * A through T for primary dentition * Add S to primary dentition letter to indicate supernumerary teeth associated with primary dentition (for example, AS through TS). CONDITIONAL FIELD 28 Tooth Surface For tooth-specific services, enter the appropriate surface code. Acceptable codes are listed below. B - Buccal D - Distal F - Facial I - Incisial L - Lingual M - Mesial O – Occlusal CONDITIONAL FIELD 29 Procedure Code Enter the five-character service code from Subchapter 6 of the Dental Manual or from Appendix E of the Dental Manual (for oral surgery) that describes the service provided. If billing with a service code that requires a report, attach a copy of the report to the claim form. Please Note: The ADA claim form, versions 2002 and 2004, do not have a field for modifiers. Oral surgeons who need to use modifiers, such as 51 to indicate multiple procedures were performed or 80 to indicate that an assistant surgeon was required, must submit their claims containing modifiers in the HIPAA-compliant 837P format. REQUIRED FIELD 30 Description OPTIONAL FIELD 31 Fee Enter the provider’s usual fee (the usual charge to the general public for the same or a similar service). Do not list services for which no charge was made. All services listed in Subchapter 6 of the Dental Manual or Appendix E of the Dental Manual that require individual consideration also require PA, so the fee paid will be the authorized fee on the PA. REQUIRED FIELD 32 Other Fees LEAVE BLANK 33 Total Fee Enter the sum of fees from all lines in Field 31. REQUIRED FIELD Missing Teeth Information     34 Missing Teeth Information OPTIONAL FIELD 35 Remarks Use this field to indicate if the claim is a resubmittal or an adjustment. For resubmittals that require a transaction control number (TCN) (see All Provider Bulletin 123, dated May 2003), enter “R” followed by the 10-character TCN assigned to the original claim. For adjustments, enter “A” followed by the 10-character TCN assigned to the most recently paid claim. CONDITIONAL FIELD The TCN appears on the remittance advice that listed the claim as paid or denied. Left-justify all information and begin text immediately following the word “Remarks.” Nothing other than resubmittal or adjustment information should be entered in this field. Authorizations     36 Patient Consent OPTIONAL FIELD 37 Insured's Signature   OPTIONAL FIELD Ancillary Claim/Treatment Information   38 Place of Treatment Enter an X in the Provider's Office box if the services were performed in an office. Enter an X in the Hospital box for inpatient and outpatient hospital services. Enter an X in the ECF box if the services were performed in an extended care facility (for example, nursing facility). Enter an X in the Other box if none of the other place-of-service indicators apply (for example, school-based services). If the member received services in multiple places of service, submit a separate claim for each place of service. REQUIRED FIELD 39 Number of Enclosures   OPTIONAL FIELD 40 Is Treatment for Orthodontics? OPTIONAL FIELD 41 Date Appliance Placed If completed, provide the date in one of the following three formats: MM/DD/CCYY, MM-DD-CCYY, or MMDDCCYY. OPTIONAL FIELD 42 Months of Treatment Remaining OPTIONAL FIELD 43 Replacement of Prosthesis? OPTIONAL FIELD 44 Date Prior Placement OPTIONAL FIELD 45 Treatment Resulting from (Check applicable box.) If the dental treatment listed on the claim was provided as a result of an accident or injury, check the appropriate box in this field, and proceed to Field 46. If the services you are providing are not the result of an accident or injury, skip to Field 48. CONDITIONAL FIELD 46 Date of Accident (MM/DD/CCYY) Enter the date on which the accident or injury noted in Field 45 occurred in one of the following three formats: MM/DD/CCYY, MM-DD-CCYY, or MMDDCCYY. Otherwise, leave blank. CONDITIONAL FIELD 47 Auto Accident State OPTIONAL FIELD Billing Dentist or Dental Entity     48 Name, Address, City, State, Zip Code Enter the name and complete address of the dentist or the dental entity (corporation or group). REQUIRED FIELD 49 Provider ID Enter the seven-digit MassHealth pay-to-provider number. If the dental provider furnished the service as part of a group practice, enter the seven-digit provider number assigned by MassHealth to the group. Enter the seven-digit MassHealth provider number assigned to the individual dentist if payments are to be made to the individual provider. REQUIRED FIELD 50 License Number OPTIONAL FIELD 51 SSN or TIN OPTIONAL FIELD 52 Phone Number OPTIONAL FIELD 53 Certification Provide the signature of the treating dentist and the date the form is signed. This is the dentist who performed procedures indicated by date, for the patient. Provider signatures on the claim form may be handwritten, typed, stamped, or electronic. REQUIRED FIELD Treating Dentist and Treatment Location Information   54 Provider ID If the provider furnished the service as part of a group practice, enter the seven-digit MassHealth provider number assigned to the individual provider. Complete this field only if the information in this field is different from the information contained in Field 49. CONDITIONAL FIELD 55 License Number OPTIONAL FIELD 56 Address, City, State, Zip Code OPTIONAL FIELD 57 Phone Number OPTIONAL FIELD 58 Treating Provider Specialty   OPTIONAL FIELD MassHealth Dental Bulletin 35 June 2006 Page 2