How to file claims

Do use:

• Fees with decimal points (for example, 100.00; not 100)
• Indicate a quantity (the number of x-rays, for example) in the field on the claim specifically for this purpose. If this field is not available, list each item on a seperate line.
• Attach the primary carriers EOB or write the amount primary paid in the remarks sections

The following may cause delays, inaccurate processing and possible denials:

• Non-treatment related messages in the remarks section (for example, 2nd submission; please process)

Do use:

• A laser printer with black or blue ink
• A 10-point font and all capital letters (Courier is a good font choice)
• Six-digit dates with no spaces, slashes or dashes (for example, 050312 for May 3, 2012)
• Fees with decimal points (for example, 100.00; not 100)
• 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.
• Attach the primary carrier’s EOB or write the amount primary paid in the remarks section
  
  

The following may cause delays, inaccurate processing and possible denials:

• Using red ink
• Using free-form text — Use ditto marks or arrows to indicate duplicate information
• Hand-written claims
• Stray marks in spaces that should be left blank
• Putting a slash through zeros or crossing sevens
• Writing on top of lines or outside of boxes
• Using correction fluid or a highlighter pen
• Using more than one font style on a claim
• Submitting photocopied claims as they are generally received blurred or skewed
• Using nicknames for either the subscriber or patient
• Non-treatment related messages in the remarks section (for example, 2nd submission; please process)

• Indicate if the patient has other coverage with another dental plan (for example, in oral surgery cases with a medical plan) by checking the “Other insurance coverage” box, or something similarly titled. When there is other insurance coverage, be sure to complete all the other information fields in this same area on the claim form.
• When Delta Dental is the secondary carrier the primary carrier’s Explanation of Benefits or remittance advice is not required; please just indicate the amount paid by the primary carrier on the claim in the “Other coverage” area.

If you have submitted a pre-treatment estimate, once services are provided use the notification of pre-treatment estimate form. You only have to date each service, sign and return the form for processing. Line through (single line) any treatment that has not been completed. Do not submit a new claim for any services that have been submitted for a pre-treatment estimate.

See "Pre-treatment estimates" for more information.

• Copies of radiographs must be of diagnostic quality.
• We accept duplicate films and paper copies of digital images.
• Radiographs or other documentation is not returned.
• X-rays for your for your Delta Dental Premier® and Delta Dental PPOSM 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
  • Radiographs or other documentation is not returned.
  • Prosthodontics, fixed: D6710-D6794, fixed partial denture retainers, crowns
• 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.

The Tax ID you use on your claims affects your year-end 1099 statement. Any changes to this ID number during the year should be verified through your local Delta Dental Member Company no later than the end of each year. No changes to the ID number can be made on the 1099 statements once they have been processed.

The tax identification number and practice name on file with Delta Dental must match the IRS records exactly. If they do not, the IRS requires Delta Dental to withhold 28 percent of the dollars owed to you from future payments until the matter is resolved. Use the tips here when submitting your claims:

• If two or more names are used (such as Chris Smith, DMD, dba Market Street Dental), please give us the first listing that appears on the IRS records, in this example Chris Smith, DMD.
• If you are unsure of how your practice name and the associated ID number are recorded with the IRS, check what is printed on the mailing labels that are supplied by the IRS for quarterly tax payments. Or, you may contact the IRS to request a letter (#147C) that will confirm their records of your name and ID number. The IRS phone number is 800-829-1040.

The federal Health Insurance Portability and Accountability Act (HIPAA) requires you to obtain a NPI if you submit claims electronically. Additionally if you verify claims status or access patient enrollment and/or benefits information online you are required to use a NPI. All individual health care providers (including dentists) and organizations such as clinics and group practices are eligible to obtain an NPI.

A “Yes” response to any one of the following questions requires you to obtain and use an NPI per federal law.

• Do you submit claims electronically?
• Do you use a clearinghouse?
• Do you submit claims attachments electronically?
• Do you use the Internet to obtain eligibility, benefits information or check claims status?

• A 10-digit random number unique to each health care provider or organization
• An NPI contains no coded information about the provider or organization
• A permanent identifier that does not change over time or expire
• A replacement for other identifying numbers currently used in electronic transactions, such as the Medicaid, Blue Cross and Blue Shield, UPIN, CHAMPUS and certain other “legacy” numbers
• Not a replacement for social security numbers, DEA numbers, taxpayer ID numbers (TIN or EIN), specialty identifiers (taxonomy) or state license numbers
• Issued by the government through a third-party group, the National Plan & Provider Enumeration System (NPPES), which is responsible for processing applications and assigning numbers

There are two types of NPIs: Type 1, for individual health care providers, such as dentists and hygienists, and Type 2 for incorporated businesses, such as group practices and clinics. When submitting claims, the NPI-1 will always be required for the rendering/treating dentist.

Overpayment of a claim

Delta Dental may automatically recover overpayment of a claim from future payment checks that may or may not be for claims submitted on behalf of the same patient for whom the overpayment was originally made. Utilize Dental Office Toolkit (DOT) (https://ddfgptoolkits.com) to check claim status.