Required information on a claim

A claim or pre-treatment estimate automatically contains the required provider and patient information, which is selected when the claim is created.

In order to submit a claim or pre-treatment estimate for processing, additional information must be entered or selected for at least one claim line on the Treatment Details tab. Fields on the other tabs are optional.

The procedure code and the submitted amount are always required. Certain procedure codes may require tooth code(s), an oral cavity, and/or surface(s). A service date is required except for pre-treatment estimates.

Tooth Code — if necessary, enter the tooth number of the tooth on which the procedure was performed; only one tooth code can be entered on a claim line.
Area of Arch — the horseshoe (U)-shaped arrangement of the teeth and bone (upper left quadrant, upper right quadrant, lower left quadrant, or lower right quadrant). If necessary, enter the code for the area of in which the procedure was performed; only one area can be entered on a claim line.
Surface(s) — if necessary, select the surface (s) on which the procedure was performed; up to five surfaces can be selected per claim line.
Service Date — enter the date the procedure was performed, in the format mm/dd/yyyy, or leave blank for a pre-treatment estimate; a claim may contain claim lines with different service dates.
Proc Code — enter the CDT procedure code number (e.g., 120 for a periodic oral evaluation).
Submit Amt — enter the amount being charged per claim line.

To add additional lines to a claim, select the Add More Treatment Lines button. A new line will appear.

Add comments to the claim by filling in the Remarks section. All electronic attachments should be noted in this field.

To view a list of procedure codes, select the click here link under the Remarks section. The Dental Procedure Codes screen appears listing the code number and description of the procedure.

Additional claim details concerning the patient (account number, assignment of benefits, and more) can be added on the Claim Details tab of the claim form; see Submitting a claim with special patient information. If the patient has other coverage, see Submitting a claim with coordination of benefits for help with the COB Details tab. If one or more of the claim lines include orthodontic procedures, see Submitting an ortho claim for help with the Ortho Details tab.