Dental Claim Submission Requirements & Dental Policy Updates

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Effective Oct. 1, 2015, the South Carolina Department of Health and Human Services (SCDHHS) will require providers to submit the 2012 American Dental Association (ADA) claim form, or its corresponding Electronic Data Interchange (EDI) format, when filing dental or oral surgical claims services using Common Dental Terminology (CDT) procedure codes. Previously used ADA claim forms and their accompanying EDI formats will be rejected for all claims submitted on or after Oct. 1, 2015.

 

Major changes on the 2012 ADA Claim Form

Diagnosis Codes

The updated 2012 ADA Dental Claim Form incorporates key Health Insurance Portability and Accountability Act (HIPAA) changes and includes a new section for diagnostic coding (Field 34) using  either ICD-9 or ICD-10 formats. SCDHHS encourages dental providers to include appropriate diagnosis coding within Field 34. All diagnoses submitted will be stored by SCDHHS’ dental administrator, DentaQuest.

Place of Service Codes

The 2012 ADA claim form allows for specific indication of place of service (Field 38) using the standardized values for professional claims.

SCDHHS requires valid place of service codes when submitting claims on the 2012 ADA claim form. Examples of routinely utilized place of service codes include:

 

03 School

22 Outpatient Hospital

11 Office

23 Emergency Room

15 Mobile Dental Unit

24 Ambulatory Surgical Center

21 Inpatient Hospital

50 Federally Qualified Health Center

 

Quantity

The 2012 ADA claim form allows for the entry of quantity (Field 29b); however, for reporting to SCDHHS at this time, quantity MUST be entered as one (1).

For additional instruction on completing the 2012 ADA claim form please visit the ADA website at http://www.ada.org/en/publications/cdt/ada-dental-claim-form .

Claim Submission Options

SCDHHS’ dental administrator, DentaQuest, has a free web-based claims submission tool that may be used by dental providers. For those practices that are unable to switch to the 2012 ADA Claim Form by the Oct. 1, 2015, deadline, you must utilize this web-based submission tool to avoid rejection of all claims. DentaQuest offers free training to dental providers on how to submit claims rapidly through the Web Portal. The Web Portal allows providers to efficiently enter member and claims information, run reports and submit authorizations and claims for overnight receipt. If you would like to discuss this option, please contact DentaQuest at (888) 307-6553. 

 

Dental Policy Updates

Beginning with claims submitted on or after Oct. 1, 2015, a limited oral evaluation – problem focused exam (D0140) will be denied if billed with a preventive service, such as a fluoride treatment. Preventive services are allowable if billed in conjunction with D0120 or D0150 evaluation codes.

Please refer any questions or concerns regarding this bulletin to the DentaQuest Provider Call Center at (888) 307-6553. Thank you for your continued support of the South Carolina Healthy Connections Medicaid Program. 

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