Claim Completion Instructions

Use these tips for clear, complete claims that will move smoothly through our system.

DO use:

• A laser printer with black ink
• A 10 point font and all capital letters (Courier is a good font choice)
• Eight-digit dates with no spaces, slashes or dashes (for example, 05032012 for May 3, 2012)
• Standard size paper (8.5 x 11 inch) for claims and written documentation
• Fees with decimal points (for example, 100.00; not 100)

DON'T

• Use free-form text — use the “Tooth number or letter” field to indicate quadrant or arch (UR or L, for example)
• Use ditto marks or arrows to indicate duplicate information
• Allow stray marks in spaces that should be left blank
• Use slashed zeros and crossed sevens
• Write on top of lines or outside of boxes
• Use correction fluid or a highlighter pen
• Use more than one font style on a claim
• Use photocopied claims that are blurred or skewed

More Tips for Electronic and Paper Claims

Claim form completion

• Thoroughly complete the claim with clear, legible information.
• Do not use patients’ nicknames.
• Document exceptional or unusual circumstances only in the “Remarks” or “Comments” field of the claim. Better yet, send the documentation on a separate attachment (8.5 x 11 inch paper) or transmit it digitally.
• Indicate a quantity (the number of x-rays, for example) in the field on the claim specifically for this purpose. If the claim does not have this field, please list each item on a separate line.
• Be sure to enter the name of the dental plan enrollee in the space provided at the top of the form and in the dual coverage section, if applicable. (The enrollee is the person who has the dental plan through his/her employment. In dual coverage cases, there will usually be two different enrollees within a family.)
• Enter a valid National Provider Identifier (NPI). If you enter two NPIs (one for the billing dentist and another for the treating dentist, if it is different from the billing entity’s NPI), please verify that they are both valid.

Dual Coverage

• Indicate if the patient has (or does not have) dual coverage with another dental plan (or sometimes, in oral surgery cases for example, with a medical plan) by checking the specific box, usually found in a field titled “Other insurance coverage” or something similar. If there is dual coverage, be sure to include all the requested information.
• Always include the primary carrier’s Explanation of Benefits or remittance advice document when Delta Dental is the secondary carrier.
• If dual coverage is through the same Delta Dental company, submit one claim with information entered about both enrollees. We will process the primary and secondary benefits from that one claim. NOTE: You may not receive payment for both coverages on the same check because the secondary coverage may be processed a few days after the primary coverage. See “Dual Coverage” for more information.

Orthodontic Claims

Please don’t send claims for monthly orthodontic visits. To make it easier for you, your fees for these visits are included in the total fee you submit on the claim for banding and in the periodic payments you automatically receive from Delta Dental. See “Orthodontics” for more information.

Pre-treatment Estimates

Send a new claim for payment after services are provided (do not date and return the pre-treatment estimate). In the “Remarks” or “Comments” section, include the Delta Dental reference number found on the original pre-treatment estimate, or write “Pre-treatment estimate on file” if you no longer have the reference number. See “Pre-treatment estimates” for more information.

Documentation

• X-rays for your for your Delta Dental Premier^® and Delta Dental PPO^SM claims are necessary only for these procedures:
  • Restorative: D2710-D2794, crowns — laboratory processed, and D2950, core buildup, including any pins
  • Implant services: D6055-D6077, implant supported prosthetics
  • Prosthodontics, fixed: D6710-D6794, fixed partial denture retainers, crowns
• X-ray copies submitted with paper claims must be of diagnostic quality. We will accept duplicate films and paper copies of digital images.
• We do not return x-rays or other documentation submitted with paper claims; however, we will make an exception when we receive a stamped, self-addressed envelope with the claim.
• Periodontal charting is necessary for osseous and other periodontal surgery procedures in this procedure code range: D4260-D4276.
• A copy of the pathology report is needed for hard and soft tissue biopsies: D7285-D7286.
• Narratives need to be included for the unspecified codes in all categories of service (D##99). Enter the information in the “Remarks” or “Comments” field.

Submit all Your Claims and Attachments Electronically

You don’t need to send a paper claim when an attachment is necessary. Use FastAttach^®, a service available through National Electronic Attachment, Inc. (NEA), to electronically transmit digitized x-rays, periodontal charts, Explanation of Benefits documents, photos and narratives.

If you are not submitting claims electronically, talk with your practice management system vendor about activating your system’s electronic claims component.

Delta Dental and its affiliate companies are installing MetaVance Benefit Administration Software as the claims editing software product to provide timely and efficient adjudication for dental claims. This software is helping our enterprise streamline many interrelated systems and processes, as well as increase functionality for the benefit of our dentists, enrollees and customers.

Dependents Age 19 and Over

For full time students, enter the name of the school and the city in which it is located on the claim. If the patient is a dependent with a disability, enter the nature of the disability.

Tax Identification Number (TIN)

Enter the TIN of the billing dentist or dental entity. Inform your local Dentist Network Administration and Contracting department if your TIN or the name associated with that TIN changes.

National Provider Identifier (NPI)

Use claim forms that accommodate the NPI by providing a specific space for it. (This might require you to upgrade your software.) Enter the NPI of the billing dentist or dental entity, as well as the treating dentist's NPI (if they are different). Verify that the NPIs are valid.

Electronic Encounter Forms for DeltaCare^® USA

You can save time and money while helping the environment by electronically submitting your encounter forms to DeltaCare USA.

• Saving money by eliminating printing, copying and mailing costs.
• Saving time by submitting electronic encounter forms daily, which can eliminate the need to spend more time running monthly reports.
• Receiving prompt notification of any invalid data, allowing you to make the necessary corrections and re-submit right away.
• Receiving reports of all successfully transmitted encounter forms, reducing follow-up on unpaid submissions.

DeltaCare USA's payer identification number for encounter forms is DDCA3.

For more information about electronic encounter form submission, please email our Encounters department.