May 2020 Volume LV Number 3


Coding Corner

November 2019 Volume LIV Number 6

Know Where Auditors Look for Fraud on the Dental Claim Form
The 2012 ADA Dental Claim Form is the most commonly accepted method of  communicating treatments provided to patients in a consistent way, and is accepted by payers as the method to submit claims for reimbursement. v2019_ADA%20DentalClaimCompletionInstructions_2019May20.pdf ?la=en.
There are certain responsibilities associated with claim submissions. Most importantly, it is necessary to realize that the claim form is a legal document, signed by the doctor. There is a moral and legal obligation that the information conveyed on that dental claim form is accurate and true. If  completed with errors or inaccurate information, there may be some significant repercussions, even legal action.
This feature details some of  the more common areas of  concern.
If  the procedure is anticipated, but has not begun, the predeter- mination box should be checked and there should be no associated dates of  services listed. If  the treatment has been initiated, but is not complete, check the box that indicates the claim is a "statement of actual services."" Fewer than five percent of  dental plans allow service to be billed on the start date. The incurred liability date (the date the service may be billed) may be determined when verifying benefits or by calling the payer's provider relations representative and asking the question, ""May services that require multiple appointments be billed on start date?"
If the wrong box is checked and payment is received in error, return the EOB with a notification that the incorrect box was checked. Request that the claim be reprocessed as a predetermination. Do not cash the check or hold the check in anticipation that the service will be completed."
Always check the boxes that apply. If  the patient has medical and dental coverage for their dental services, you must check both boxes to provide accurate information to the payer. Medical coverage is al- most always primary and should be submitted first. Vhen/if  payment is received from the patient's medical plan, attach a copy of  the medi- cal reimbursement EOB to the dental claim and check both dental and medical boxes, and identify the other plan covering the patient's treatment in Box 11.
BOX 29
Always select the most accurate code to describe the service pro- vided. Be careful to use the most current and accurate CDT code in Box 29. Using an incorrect code and receiving inappropriate reim- bursement can be viewed as fraud. Even an ""innocent mistake"" may be viewed as "blind disregard for the truth" and can lead to significant challenges, especially if  the errors are frequent and no compliance program is in place.
An outline of  the mandated seven step compliance program can be found at effective-compliance.
BOX 33
When pertinent to periodontal, prosthodontic (fixed and remov- able), or implant services, many plans require that all missing teeth be identified. This may be true even if  the treatment only involves one missing tooth. Accurate information for the missing teeth will often prevent delays or requests for additional information from the payer before reimbursement is considered.
BOX 34 AND 34A
Some states and payers require this area be completed. Comple- tion is most frequently required for government reimbursed plans.
BOX 35
This box is used to convey additional information for a procedure code that requires a report or to convey additional information neces- sary for the payer to process the claim. Remarks should be concise and pertinent to the claim submission. If  the claim form is submitted electronically, only 80 characters should be transmitted. Longer re- marks should be forwarded to the payer via attachment. Note that an entry in the "Remarks" section may prompt review by a person as part of  claim adjudication, which may impact the overall time required to process the claim.
BOX 36
This box states: "I (the patient) have been informed of  the treat- ment plan and associated fees. I agree to be responsible for all 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 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 pay- ment activities in connection with this claim."
A copy of  a treatment plan signed by the patient should be main- tained in the patient's clinical record.
BOX 37
This box states: "I (the patient) hereby authorize and direct pay- ment of  the dental benefits otherwise payable to me, directly to the below named dentist or dental entity."
A copy of  the patient's dated and signed authorization of  benefits to the practice should be maintained in the patient's record.
Note: Some plans (including most Delta Dental Plans) will not honor this request, even if  signed by the patient, unless the state has adopted legislation mandating that the patient request of  assignment of  benefits be honored. Check with your state's dental association for information regarding the legislation in your state.
BOX 38
Place of  treatment must be accurately identified. If  the doctor has multiple locations or if  the treatment was provided in a hospital set- ting,  make sure the correct location is listed.
BOX 40
Is the treatment for orthodontics? The box should accurately reflect the reason for the treatment. This may seem straightforward, but orthodontic treatment could include extraction of  teeth that are crowded as part of  the orthodontic plan. All treatments provided in relation to or to aid with orthodontic treatment should be identified as part of  the overall orthodontic treatment.
BOX 45
If  the treatment was necessary because of  an occupational injury or accident, auto accident, or other accident (e.g., slip or fall), the ap- propriate box should be checked. when this is the case, any accident coverage would then become primary. The treatment should be sub- mitted to the plan covering the accident (e.g., auto insurance, medical insurance, employer's liability plan, etc.).
BOXES 48 – 52
These areas are completed if  payment is directed to an entity other than the treating dentist. Do not complete this section if  payment is to be directed to the patient.
BOX 53
Signature of  the treating or rendering dentist and the date the form is signed should be accurate. This box should accurately identify the dentist who performed, or is in the process of  performing, pro- cedures, indicated by date. This includes accurately identifying the dentist who supervised a qualified individual performing the service. Under no circumstances should another provider be listed as the pro- vider of  service, regardless of  the individual's participation status. 
Note: If  the claim form is being used to obtain a pre-estimate or pre-authorization, it is not "necessary for the dentist to sign the form."
Ultimately, the dentist and team need to be aware that the claim form submitted to the payer for reimbursement is a legal document. All information provided on and with that claim, must be accurate.
Questions or concerns can be sent to Dental Benefits Director Mary Essling at (312) 337-2169 or

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