Healthplex Claim Form For All Groups Administered Page 2

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CLAIMS BARCODE

GOES HERE

Any person who knowingly and with intent to defraud any insurance company or other person ﬁles an application for insurance or statement of claim containing any

materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a

crime, and shall be subject to a civil penalty not to exceed ﬁve thousand dollars and the stated value of the claim for each such violation.

GENERAL INSTRUCTIONS

Complete all items unless noted otherwise on the form or in the CDT manual’s instructions.

Enter the full name of an individual or a full business name, address and zip code when a name and address ﬁeld is required.

All dates must include the four-digit year.

If the number of procedures reported exceeds the number of lines available on one claim form, list the remaining procedures on a

separate, fully completed claim form.

COORDINATION OF BENEFITS (COB)

When a claim is being submitted to the secondary payer, complete the entire form and attach the primary payer’s Explanation of Beneﬁts (EOB) showing the amount paid

by the primary payer. You may also note the primary carrier paid amount in the “Remarks” ﬁeld (Item 35). There are additional detailed completion instructions in the CDT

manual.

DIAGNOSIS CODING

The form supports reporting up to four diagnosis codes per dental procedure. This information is required when the diagnosis may aﬀect claim adjudication when speciﬁc

dental procedures may minimize the risks associated with the connection between the patient’s oral and systemic health conditions. Diagnosis codes are linked to

procedures using the following ﬁelds:

Item 29a – Diagnosis Code Pointer (“A” through “D” as applicable from Item 34a)

Item 34 – Diagnosis Code List Qualiﬁer (B for ICD-9-CM; AB for ICD-10-CM)

Item 34a – Diagnosis Code(s) / A, B, C, D (up to four with the primary adjacent to the letter “A”)

PLACE OF TREATMENT

Enter the 2-digit Place of Service Code for Professional Claims, A HIPAA standard maintained by the Centers for Medicare and Medicaid Services. Frequently used codes are:

11 = Oﬃce

12 = Home

21 = Inpatient Hospital

22 = Outpatient Hospital

31 = Skilled Nursing Facility

32 = Nursing Facility

The full list is available online at “

PROVIDER SPECIALTY

This code is entered in Item 56a and indicated the type of dental professional who delivered the treatment. The general code listed as “Dentist” may be used instead of any

of the other codes.

Category / Description Code

Code

Dentist

122300000X

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.

General Practice

1223G0001X

Dental Specialty (see following list)

Various

Dental Public Health