Dental Claim Form HEADER INFORMATION 1. Type of Transaction (Check all applicable boxes) Statement of Actual Services Request for Predetermination / Preauthorization EPSDT/ Title XIX PRIMARY INSURED INFORMATION 2. Predetermination / Preauthorization Number 12. Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code PRIMARY PAYER INFORMATION 3. Name, Address, City, State, Zip Code CIGNA Dental P.O. Box 188037 Chattanooga, TN 37422-8037 15. Subscriber Identifier (SSN or ID#) 14. Gender 13. Date of Birth (MM/DD/CCYY) M OTHER COVERAGE 16. Plan/Group Number 4. Other Dental or Medical Coverage? 17. Employer Name 3154192 Yes (Complete 5-11) No (Skip 5-11) F Indiana University PATIENT INFORMATION 5. Other Insured’s Name (Last, First, Middle Initial, Suffix) 6. Date of Birth (MM/DD/CCYY) Self 8. Subscriber Identifier (SSN or ID#) 7. Gender M F Spouse Dependent Child 19. Student Status FTS Other PTS fold fold 18. Relationship to Primary Insured (Check applicable box) 20. Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code 10. Patient’ s Relationship to Other Insured (Check applicable box) 9. Plan/Group Number Self Spouse Dependent Other 11. Other Carrier Name, Address, City, State, Zip Code 22. Gender 21. Date of Birth (MM/DD/CCYY) 23. Patient ID/Account # (Assigned by Dentist) M F RECORD OF SERVICES PROVIDED 25. Area 26. of Oral Tooth Cavity System 24. Procedure Date (MM/DD/CCYY) 28. Tooth Surface 27. Tooth Number(s) or Letter(s) 29. Procedure Code 30. Description 31. Fee 1 2 3 4 5 6 7 8 9 10 MISSING TEETH INFORMATION Permanent Primary 1 4 5 6 7 8 9 10 11 12 13 14 15 16 A B C D E F G H I J 32. Other Fee(s) 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 T S R Q P O N M L K 33.Total Fee fold fold 3 32 34. (Place an 'X' on each missing tooth) 2 35. Remarks AUTHORIZATIONS ANCILLARY CLAIM/TREATMENT INFORMATION 36. I have been informed of the treatment 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 payment activities in connection with this claim. 38. Place of Treatment (Check applicable box) Provider’s Office Hospital Patient /Guardian signature Date 37. I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to the below named dentist or dental entity. 42. Months of Treatment Remaining Model(s) 41. Date Appliance Placed (MM/DD/CCYY) Yes (Complete 41-42) 44. Date Prior Placement (MM/DD/CCYY) Yes (Complete 44) 45. Treatment Resulting from (Check applicable box) Auto accident Occupational illness / injury Date Oral Image(s) Other 43. Replacement of Prosthesis? No X Subscriber signature Radiograph(s) ECF 40. Is Treatment for Orthodontics? No (Skip 41-42) X 39. Number of Enclosures (00 to 99) Other accident 47. Auto Accident State 46. Date of Accident (MM/DD/CCYY) BILLING DENTIST OR DENTAL ENTITY (Leave blank if dentist or dental entity is not submitting TREATING DENTIST AND TREATMENT LOCATION INFORMATION claim on behalf of the patient or insured/subscriber) 53. I hereby certify that the procedures as indicated by date are in progress (for procedures that require multiple visits) or have been completed and that the fees submitted are the actual fees I have charged and intend to collect for those procedures. 48. Name, Address, City, State, Zip Code X Date Signed (Treating Dentist) 54. Provider ID 55. License Number 56. Address, City, State, Zip Code 49. Provider ID 52. Phone Number ( 50. License Number ) – © 2002, 2004 American Dental Association J515 (Same as ADA Dental Claim Form – J516, J517, J518, J519) 51. SSN or TIN 57. Phone Number ( ) – 58. Treating Provider Specialty American LegalNet, Inc. www.USCourtForms.com To Reorder call 1-800-947-4746 Cat. #590154 Rev. 2-05 or go online at www.adacatalog.org Comprehensive completion instructions for the ADA Dental Claim Form are found in Section 6 of the ADA Publication titled CDT-2005. Key extracts from that section of CDT-2005 follow: GENERAL INSTRUCTIONS A. The form is designed so that the Primary Payer’s (primary insurance company) name and address (Item 3) are visible in a standard #10 window envelope. Please fold the form using the ‘tick-marks’ printed in the margin. B. In the upper-right of the form, a blank space is provided for the convenience of the payer or insurance company, to allow the assignment of a claim or control number. C. All Items in the form must be completed unless it is noted on the form or in the comprehensive instructions that completion is not required. D. When a name and address field is required the full name of an individual or a business, address and zip code must be entered. E. All dates must include the four-digit year. F. If the number of procedures reported exceeds the number of lines available on one claim form, the remaining procedures must be listed on a separate, fully completed claim form. COORDINATION OF BENEFITS (COB) When a claim is being submitted to a secondary payer, complete the form in its entirety and attach the primary payers Explanation of Benefits (EOB) showing the amount paid by the primary payer. You may indicate the amount the primary carrier paid in the “Remarks” field (Item # 35). ITEMS OF NOTE 39. Number of Enclosures (00 to 99): This item is completed whether or not radiographs, oral images, or study models are submitted with the claim. If no enclosures are submitted, enter 00 in each of the boxes to verify that nothing has been sent and therefore no possible attachments are missing. When supplementary material is sent with the claim, the number of each type is entered in the appropriate box, using two digits. If less than 10, use 0 in the first position. ‘Oral Images’ include digital radiographic images and photographs and are reported by the number of images. 43. Replacement of Prosthesis?: This Item applies to Crowns and all Fixed or Removable Prostheses (e.g. bridges and dentures). Please review the following three situations in order to determine how to complete this Item. a) If the claim does not involve a prosthetic restoration check “NO” and proceed to Item 45. b) If the claim is for the initial placement of a crown, or a fixed or removable prosthesis, check “NO” and proceed to Item 45. c) If the patient has previously had these teeth replaced by a crown, or a fixed or removable prosthesis, or the claim is to replace an existing crown, check the “YES” field and complete section 44. 53. Certification: Signature of the treating or rendering dentist and the date the form is signed. This is the dentist who performed, or is in the process of performing, procedures indicated by date for the patient. 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. Dentists should be aware that they have an ethical and legal obligation to refund fees for services that are paid in advance but are not completed. PROVIDER TAXONOMY CODES 58. Treating Provider Specialty: Enter the code that indicates the type of dental professional who delivered the treatment. Available codes describing treating dentists are listed below. The general code listed as ‘Dentist’ may be used instead of any other dental practitioner code. Category / Description Code Code Dentist / A dentist is a person qualified by a doctorate in dental surgery (D.D.S) or dental medicine (D.M.D.) 122300000X licensed by the state to practice dentistry, and practicing within the scope of that license. General Practice / Many dentists are general practitioners who handle a wide variety of dental needs. 1223G0001X Various Dental Specialty / Other dentists practice in one of the nine specialty areas recognized by the American Dental Association. (see following list) Dental Public Health 1223D0001X Endodontics 1223E0200X Orthodontics 1223X0400X Pediatric Dentistry 1223P0221X Periodontics 1223P0300X Prosthodontics 1223P0700X Oral & Maxillofacial Pathology 1223P0106X Oral & Maxillofacial Radiology 1223D0008X Oral & Maxillofacial Surgery 1223S0112X Dental provider taxonomy codes listed above are a subset of the full code set that is posted at: http://www.wpc-edi.com/codes/codes.asp Any updates to ADA Dental Claim Form completion instructions will be posted on the ADA’s web site at: www.ada.org/goto/dentalcode American LegalNet, Inc. www.USCourtForms.com