california medi-cal dental program

CALIFORNIA MEDI-CAL DENTAL

PROGRAM

BASIC AND EDISEMINAR PACKET

Revised 12292021

--------------------

t~ srrille CALIFORNIA MEDI-CAL HAS DENTAL COVERED

2B-PRL-TRN-006AC

PO Box 15609 bull Sacramento CA 95852-0609 bull (800) 423-0507 bull (916) 853-7373

Dear Medi-Cal Dental Provider and Staff

Welcome This seminar has been designed for dental providers and office staff whoparticipate in the California Medi Cal Dental Program

The material contained in the training packet has been prepared to help familiarize youwith the Medi-Cal Dental Programs policies procedures and billing requirements Youshould also refer to the Medi-Cal Dental Program Provider Handbook located on theMedi-Cal Dental Program website at wwwdentaldhcscagov for additional information

We hope that you will benefit from the information presented at todayrsquos seminar If youhave any questions please call our provider toll-free line at (800)-423-0507

Sincerely

Medi-Cal Dental Program

3B-PRL-TRN-006AC

DHCS I 1edi Cal Dental


P O Box 15609(Sacramento CA 95852-0609((800) 423-0507((916) 853-7373

California Medi-Cal Dental ProgramBASIC TRAINING SEMINAR

Introduction

This packet contains the information discussed in todayrsquos seminar regarding basic billingprocedures and the use of forms Please refer to the Medi-Cal Dental Program ProviderHandbook for detailed step-by-step instructions on how to complete each form

When discussing the Medi-Cal Dental program some terminology may be unfamiliarThe seminar packet contains a glossary listing some of the terms mentioned in todayrsquosseminar

Program Overview

Medi-Cal Dental is the dental portion of the State Medicaid Program Delta Dental ofCalifornia administers the Fee-For-Service portion of the dental program for theDepartment Of Health Care Services (DHCS) Our function as administrators of thisprogram is to process your TARClaim forms and to enforce the rules and guidelines setby DHCS

4B-PRL-TRN-006AC

Program Overview

THE MEDI-CAL DENTAL PROVIDER HANDBOOK and BULLETINS

The Medi-Cal Dental Provider Handbook and Medi-Cal Dental Bulletins are available onthe Medi-Cal Dental website at wwwdentaldhcscagovThe Medi-Cal Dental Provider Handbook has been developed to assist the provider andoffice staff with participation in the Medi-Cal Dental program It contains detailedinformation regarding the submission processing and completion of all treatment formsand other related documents The Handbook should be used frequently as a referenceguide to obtain the most current criteria policies and procedures of the California Medi-Cal Dental ProgramThe Medi-Cal Dental Bulletins are published periodically to keep providers informed ofthe latest developments in the program New bulletins will appear in the ldquoWhatrsquos NewSectionrdquo of the Medi-Cal Dental website and are incorporated into the ldquoProvider Bulletinsrdquosection of the website This section should be checked frequently to ensure that youroffice has the most updated information on the Medi-Cal Dental program

5B-PRL-TRN-006AC

The Medi-Cal Dental Website wwwdentaldhcscagov

Members and Providers tabs

Publications Provider Bulletins Provider Handbook Provider Forms

Whats New

Important Reminders

Medi-Ca l Dental Providers

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6B-PRL-TRN-006AC

The Medi-Cal Dental Provider Website A lication

Welcome to the Med i-Cal Denta l Program

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The Medi-Cal Dental Provider Website Application

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BILLING PROVIDERSTo receive payment for dental services performed for eligible Medi-Cal membersprospective providers must apply and be approved by the Medi-Cal Dental ProgramNew providers are notified of their acceptance in writing after enrollment procedures arecompleted Prospective providers must not provide services to members until they havereceived the confirmation letter of acceptance in the Medi-Cal Dental Program The letterincludes the providerrsquos billing number which is the National Provider Identifier (NPI)Number that the enrollee obtained from NPPES for their type of business A secondletter includes a personal identification number (PIN) The PIN will be used to access theproviderrsquos financial informationRENDERING PROVIDERSRendering providers must be enrolled in the Medi-Cal Dental program prior to renderingservices to Medi-Cal Dental members The rendering provider number will be the NPInumber that the doctor obtained from NPPES based on their personal informationBILLING INTERMEDIARIESThe Medi-Cal Dental program will accept claims prepared and submitted by billingservices acting on behalf of providers A billing service along with the perspectiveprovider must register with the Medi-Cal Dental Program by submitting form Medi-CalDental Provider and Billing Intermediary ApplicationAgreement and required documentsUpon submission of this form with supporting documents the billing intermediary will beissued a billing intermediary number which must be included on all claims submitted onbehalf of a provider The form may be obtained by calling (800) 423-0507 writtencorrespondence or from the Medi-Cal Dental websiteBilling intermediaries must know and abide by the Medi-Cal Dental regulations Theprovider must ensure the billing intermediary knows these regulations prior to contractingwith them The provider is accountable for any incorrect or fraudulent billings submittedon their behalf Providers should ensure the billing intermediary knows where to find theProvider Handbook on the website

7B-PRL-TRN-006AC

Enrollment Billing Providers

Rendering Providers

BiHing Intermediaries

8B-PRL-TRN-006AC

Changes to the practice

Enrollment Changes bull All changes to your practice andor license

must be submitted to the Medi-Cal Dental program within 35 days of the change

bull Changes must be made in writing

bull Must include the signature of the billing provider or responsible party

Enrollment Revalidation bull Compliance with Centers for Medicare and Medicaid Services

(CMS) Final Rule

bull The Code of Federal Regulations Title 42 Section 455414 states

bull The State Medicaid agency must revalidate the enrollment of all providers regardless of provider type at least every 5 years

bull All providers are required to submmiddott a new enrollment application package in order to continue participating in the Medi-Cal Dental Program

bull Providers will receive written notification of their reenrollment when it is due

Enrollment AssistanceInquires relating to the prospective billing or rendering providers application can be directed to the Enrollment department The Enrollment department takes phone calls on Wednesday when the prospect provider has registered via the Medi-Cal Dental website (wwwdentaldhcscagov) Also the prospective billing provider can request an on-site to fill out the application with one of the outreach representative The prospective billing provider can register for the face-to-face assistance via the Medi-Cal Dental website (wwwdentaldhcscagov) Please remember that the Enrollment department will not be able to answer inquiries regarding billing or criteria those questions should be directed to the Provider Relations Representative Local Outreach Representatives or Telephone Service Center (TSC) 800-423-0507

9B-PRL-TRN-006AC

Enrollment Assistance Providers assistance line is available every Wednesday 9 Important Reminders

Enrollment on-site can be requested

Dental Enrollment Wortshops for Dental lgtroviders

ma

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ELECTRONIC FUNDS TRANSFER OF PAYMENTS

The Medi-Cal Dental program offers the ability to have Medi-Cal Dental payments transferred directly to a checking or savings account Providers may request an Electronic Funds Transfer Enrollment Form by calling the Customer Service Toll-free line at (800) 423-0507 by accessing the Medi-Cal Dental website or by writing to

California Medi-Cal Dental ProgramProvider Enrollment PO Box 15609Sacramento CA 95852-9978

When an Electronic Funds Transfer Enrollment Form is received The Medi-Cal Dental program will verify that the bank participates in electronic funds transfer A zero-dollar test deposit will be sent through the bank to verify account information A ldquozerordquo deposit to the providers account for that payment date will appear on the Explanation Of Benefits (EOB) This process usually requires three to four weeks to complete In the interim a paper check will be issued Each time an electronic deposit is made the EOB will include a statement confirming the amount of the deposit


10B-PRL-TRN-006AC

Electronic IFunds Transfer (IEFT)

Med-Cal Dental payments are deposited directly into a checking or savmiddotngs account

Complete a Electronmiddotc Funds Transfer Enrollment Form

No more wafng for the maI servmiddotce

Notification of dleposmiddotts will appear on the EOB

Provider Toll-Free Line (Medi-Cal Dental) 800-423-0507Medi-Cal Dental Website wwwdentaldhcscagov

Member Toll-Free Line (Medi-Cal Dental) 800-322-6384Member Website wwwsmilecaliforniaorg

AEVS (to verify eligibility) 800-456-2387AEVS Help Desk (Medi-Cal) 800-541-5555POSInternet Help Desk 800-541-5555Medi-Cal Website (to verify member eligibility) wwwmedi-calcagov

EDI Technical Support 916-853-7373Medi-Cal Dental Forms (fax number) 877-401-7534Health Care Options 800-430-4263CA Department of Public HealthhttpswwwcdphcagovProgramsCHCQLCPCalHealthFindPagesHomeaspx

Phone Numbers and Websites

11B-PRL-TRN-006AC

12B-PRL-TRN-006AC

Eligibility

MEDI-CAL MEMBERS IDENTIFICATION

Members are required to sign their Benefits Identification Card (BIC) prior to presentingthe card for services This requirement does not apply to persons 17 years of age oryounger or to those who reside in a long-term care facility

Verification of identification is required for members who are unknown to the dental officeexcept when a member is 17 years of age or younger is receiving emergency dentalservices or resides in a long-term care facility For all other members the Medi-CalDental providers must make a ldquogood-faithrdquo effort to verify identification before providingMedi-Cal dental services A good-faith effort means matching the name and signatureon the BIC against the signature on a valid photo ID or any other document whichappears to validate and establish identity

Medi-Cal members who are unable to sign their name or make an ldquoXrdquo instead of asignature because of a disability are not required to sign their cards Providers must stillattempt to match the name on the BIC with an acceptable photo identification If aprovider does not attempt to identify a member and provides services to an ineligiblemember payment for those services may be disallowed Providers must verify eligibilityevery month for each member who presents a BIC paper Immediate Need or MinorConsent card A provider who declines to accept a Medi-Cal member must do so beforeaccessing eligibility information with the exceptions listed in the Handbook The State ofCalifornia Department of Health Care Services (DHCS) will also review claims todetermine providers who establish a pattern of providing services to ineligible membersor individuals other than the member indicated on the BIC

If a provider suspects this type of fraud or abuse is occurring he or she should report itimmediately by calling the (800) 822-6222 Monday through Friday between 800 amand 500 pm

The BIC is a permanent plastic card issued once The front of the card contains thememberrsquos ID number name birth date and issue date The reverse side contains amagnetic strip and memberrsquos signature area

The BIC is NOT a verification of eligibility but DOES contain the information to enable theprovider to access eligibility

Providers have two methods available to verify eligibility information The options are1 Touch-tone telephone2 Internet access


13B-PRL-TRN-006AC

14B-PRL-TRN-006AC

Eligibility bull The County Department of Social Services establishes eligibility

bull Information is transferred to the Department of Health Care Services (DHCS)

bull Verify eligibility monthly

bull Members turning 21 years of age

bull Eligibility Verification Confirmation Number (EVC)

Mledi-Ca Benefits Identification Card (BIC)

State of California

Benefits Identification

110 1Mo 99999999999999 Card FIRSTM lASl

M mm dd yyyy

TltisC1rd tbull for 1deutlflC1t1onONL 1t dltM11oc guorantee ellgib lluy Cony this ltgtrd with yon to yommiddot ruedi1l provld~r DO NOT THROV 11VA THIS CARD ~Ususe ltgtf this card Is unlawful

OPTIONS TO ACCESS THE POINT OF SERVICE (POS) NETWORKThe POS is set up to verify eligibility and perform Share of Cost (SOC) transactions Thenetwork may be accessed through the following ways

Touch-tone Telephone AccessWith the use of an assigned PIN all providers with a touch-tone telephone may accessthe Medi-Cal Automated Eligibility Verification System (AEVS) The automated systemwill provide eligibility and Share of Cost (SOC) information that is current and up-to-datePlease remember other information such as patient history or specific claim activity isavailable only through the Medi-Cal dental program AEVS is accessible 22 hours a day7 days a week The toll-free number to access AEVS is (800) 456-AEVS (2387)

Internet AccessThe Medi-Cal website on the internet at wwwmedi-calcagov allows providers to verifyeligibility and update Share of Cost liability This secure site is accessed by using thebilling provider number and PIN

Custom ApplicationsProviders with large claim volume and extensive computer systems may requirecustom applications to allow their system to interface with the POS network Thetechnical specifications to develop the program are available at no charge The sameeligibility and SOC information will be available to those using this method

ELIGIBILITY VERIFICATION CONFIRMATION (EVC)If the memberrsquos eligibility has been established for the month requested an EVC numberis received This number should be recorded in the patient record Please enter theEVC number in the field available on the Treatment Authorization Request (TAR)Claimform or in Box 23 on the Notice Of Authorization (NOA)


15B-PRL-TRN-006AC

16B-PRL-TRN-006AC

Eligibility

bull The Medi-Cal program verifies eligibility

bull Two ways to verify eligibility through the Point of Service (POS) Network

1) Touch Tone Telephone (AEVS) 2) Internet (wwwmedi-calcagov)

bull Request a POS NetworkInternet Agreement from the POSlnternet Help Desk or Medi-Cal

Web Elig1ibility wwwmedi-cal ca gov

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B-PRL-TRN-006AC 17

Web Eligibility wwwmedi-cal ca

Med I-Cal Providers

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18B-PRL-TRN-006AC

6 ligibility


Medi-Cal Trmsaction Services

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Swip Card

1pe Card

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Web Eligibility wwwmedi-cal cagov

Single Subscriber

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B-PRL-TRN-006AC 19

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20B-PRL-TRN-006AC

Additional Information

Aid Code information may be found in the Medi-Cal Dental Provider Handbook or on the Medmiddot-ca website

Type of Benefits soc

Aid Codes ot everyone

receiving

Medi-Cal has full-scope benefts Limited Services Restricted Services

-

bull Emergency Services Only Require an Emergency

Certification Statement

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-middot lUHUl

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21B-PRL-TRN-006AC

Aid Codes

Emergency services only aid codes (for OBRA members) contain specific emergency procedures regardless of age

- See Section 4 for the allowable procedures

22B-PRL-TRN-006AC

bull bull

bull

bull

bull

Managed Care IPlans bull Member must go to a plan provider

__ SUBSCRIBER LAST NAME XXXXXX EVC OOOO0AKEOR CNTY CODE 19 P~IMARY AID CODE 00 MEDI-CAL ELtGlBLE WI NO SOCSPENO DOWN HEALTH PLAN MEMSER PHP-HL TH NET MEDICAL CALL (800)000-0000 HPCmiddot 1 bull -~middotmiddot PCP OR XXXXX XXXX CALL (000) 000-0000

~ CESS DENTAL PLAN DENTAL CALL WOOi ooo-onmci ~

11 1lm Last First M 90000000A

1Nle-e 0 11lit ~fhti sth OnUI

MMJOOfYYYY MMDDIYYYY

~Data MMDDIYYYY 00

finl ~ lnlAld Cow Sond ~ lnlAld Cow

Diod ~ ln l ld C- --~ 19 - LO$ Angeiles

ff lC-

ace Numbu ~ Vbull IIIOKm Conliraarioa IEVCI ~

OOOOOAKEOR

Other Insurance Coverage Other Coverage ~---

Prep a id Health Plans SUBSCRIBER LAST NAME XXXXXX EVC OOOO0AKEOR CNTY CODE 11 PRIMARY AID CODE 00 MEDI-CAL ELIGIBLE WI NO SOCSPEND DOWN OTHER HEALTH IINsu~middotmiddotmiddot-- --middot UNDER CODE v

(PHP) Health CARRlER NAME BLUE CROSS OF CAUFORNIA ID XXXX0OOXXX00 COV MlPDVR -- -

Maintenance Organization (HMO) ami1 Lut FiBtM -- ID- 90000000A

erilceDate ~~ 8-th Oaltl

Indemnity Plans MMJDDfYYYY MMDDIYYYY

Medi-Cal Dental is always bilVIIDa1a Pflmor) AH Cod

MMIDDIYYYY 00

secondary carrier

Other Coverage must be Finl Sfa1 lcil Ald rbllli SCood Sfa1 lol Aid rolla

billed first Diod ~ ln l ld Cow --~ 11- Glmn

IC_

T11 riellfo mbitr ~ Vetlfl~Confl~ IEVCJ ~ OOOOOAKEOR

23B-PRL-TRN-006AC

Share of Cost middot Isa pre-set amount determined by DHCS for an individual

or family

bull Any Health Care Services may be used

bull Updating SOC

bull Case Numbers

bull Non-Covered Services may be used to meet SOC

Updating share of cost thru the POS network

EXAMPLE Patient share of cost is $87 00

Examination MM DD YY D0150 $4000

2 Bitewings MM DD YY D0272 $2700

Prophy MM DD YY D11 20 $6000

THEN Submit a claim to the Medi-Cal Dental program for all services provided

24B-PRL-TRN-006AC

Member Dental Cap $180000 Calendar year maximum A

bull Applies to adults only (21 years and over) eu bull Children are exempt (thru age 20) _f

Exclusions to the Cap e (gt bull Emergency dental servicet_ (

bull Dentures ~~ bull Maxillofacia I an co 1 ~ oral surgery

bull Se~ e~ vide middot for long-term care aid codes

r~~euroshsfovided to residents of SNIFs or CFs

Vederally mandated services (including preg1nancy-related services)

25B-PRL-TRN-006AC

Benefits Table Guide

Age Aid Code Fu ll Scope Table 4

Benefits Emergency

Full Scope aid code

Child (under 21)

Adult (21 and over) X

Member resides in an ICF or SNF

DDS Member

Al l Ages - EmergencyPregnancy aid code - Member is NOT X

p reg nan tpostpa rtu m

Member is pr~nanLp~tP5lUm (regardless of age and aid code) X

Residents of Qualifying SNF ICF ICF-DD ICF-DDH ICF-DDNI

bull These patients are eligible for additional services

bull Services do not have to be provided in the facility to be payable benefits

bull Use the website to confirm the classification and licensing of a facility (not all facilities qualify)

httpswwwcdphcaqovprogram schcglcpca lhea thfi nd PagesHome aspx

26B-PRL-TRN-006AC

Pregnant Members

bull Pregnant members regardless of age aid code andor scope of benefits are eligible to receive all dental procedures listed in the MOC

bull Includes 60 days postpartum

bull All requirements and criteria must be met

bull Must document Pregnant or Postpartum

27B-PRL-TRN-006AC

California Advancmiddotng and Innovating Medi-Cal

Overview of CalAIM

bull CalAIM is a multi-year initiative to improve the quality of life and health outcomes of the Medi-Cal population by implementing a broad delivery system program and payment reform across the Medi-Cal program

bull The major components of CalAIM were the successful outcomes of various pilots (including the Dental Transformation Initiative) from the previous federal waivers

bull All fee for service (FFS) claims will be processed and paid in accordance with the Manual of Criteria (MOC) and the Schedule of Maximum Allowances (SMA)

B-PRL-TRN-006AC 28

CalAIM effective January 1 2022 - CalAIM includes three oral health initiatives

--

Initiative 1 - Pay for Performance (P4P) - Preventive Services

bull To increase statewide uUlization of preventive services

Initiative 2 - New Caries Risk Assessment and Silver Diamine Fluoride Benefits

bull Caries Risk Assessment (CRA) bundle including the allowable fncreased frequencies for moderate and high-risk CRA bundles and Silver Diamine luoride (SDF) as new statewide dental benefits in alignment wth national dental care standards

Initiative 3 - Pay for Performance (P4P) - Continuity of Care

bull A flat rate performance payment to dental provider service office locations that maintain dental continuity of care by establishing a dental home for each patient and perform at least a yearly dental examevaluation for two or more years in a row

CalAIM Initiative 1 - Preventive Services

bull Periormance payments will be included in the weekly checkwrite for all qualified paid preventive services

bull A periormance payment at an additional 75 of the SMA

bull SNC claims will need to be validated for qualifying codes prior to issuing payment Periormance payments are earned and paid to SNC loca ions once a month

B-PRL-TRN-006AC 29

PREVENTIVE SERVICES PAY FOR PERFORMANCE FEE SCHEDULE

PROCEDURE CODE

CODE DESCRIPTION CURRENT SMA PERFORMANCE PAYMENT

MEMBERS UNDER AGE 21


MEMBERS OVER 21

D1120 PROPHYLAXIS $3000 $2250 X

D1206 TOPICAL APPLICATION OF FLUORIDE ndash VARNISH (CHILD 0 TO 5)

$1800 $1350 X


$800 $600 X

D1208 TOPICAL APPLICATION OF FLUORIDE ndash EXCLUDING VARNISH (CHILD 0 TO 5)

1800 $1350 X


$800 $600 X

D1351 SEALANT ndash PER TOOTH $2200 $1650 X

D1352 PREVENTIVE RESIN RESTORATION IN A MODERATE TO HIGH CARIES RISK PATIENT ndash PERMANENT TOOTH

$2200 $1650 X

D1510 SPACE MAINTAINER ndash FIXED ndashUNILATERAL ndash PER QUADRANT

$12000 $9000 X

D1516 SPACE MAINTAINER ndash FIXED ndashBILATERAL MAXILLARY

$20000 $15000 X

D1517 SPACE MAINTAINER ndash FIXED ndashBILATERAL MANDIBULAR

$20000 $15000 X

D1526 SPACE MAINTAINER ndash REMOVABLE ndashBILATERAL MAXILLARY

$23000 $17250 X

D1527 SPACE MAINTAINER ndash REMOVABLE ndashBILATERAL MANDIBULAR

$23000 $17250 X

D1551 RE-CEMENT OR RE-BOND BILATERAL SPACE MAINTAINER ndash MAXILLARY

$3000 $2250 X

D1552 RE-CEMENT OR RE-BOND BILATERAL SPACE MAINTAINER ndash MANDIBULAR

$3000 $2250 X

D1553 RE-CEMENT OR RE-BOND UNILATERAL SPACE MAINTAINER ndashPER QUADRANT

$3000 $2250 X

D1556 REMOVAL OF FIXED UNILATERAL SPACE MAINTAINER - PER QUADRANT

$3000 $2250 X

D1557 REMOVAL OF FIXED BILATERAL SPACE MAINTAINER ndash MAXILLARY

$3000 $2250 X

D1558 REMOVAL OF FIXED BILATERAL SPACE MAINTAINER ndash MANDIBULAR

$3000 $2250 X

D1575 DISTAL SHOE SPACE MAINTAINER ndashFIXED ndash UNILATERAL ndash PER QUADRANT

$12000 $9000 X

D1320 TOBACCO COUNSELING FOR THE CONTROL AND PREVENTION OF ORAL DISEASE

$1000 $750 X

D1999 UNSPECIFIED PREVENTIVE PROCEDURE BY REPORT

$4600 $3450 X

B-PRL-TRN-006AC 30

CalAI IM Initiative 2 - CRA and SDF Benefits

bull To receive payment for the Caries Risk Assessment (CRA) bundle dental providers must take the Trea ing Young Kids Everyday (TYKE) training hosted by the California Dental Association (CDA)

bull Providers will need to complete an attestation form and provide proof of TYKE training

bull Dental providers with an active status have completed an attestation form and TYKE training during DTI domain 2 are not required to complete these again

B-PRL-TRN-006AC 31

CalA M CRA Benefit CRA bundles includes the CRA exam (D0601 D0602 D0603) and nutritional counseling ( D 1310 ) Based on the risk level associated with each Medi-Cal member (ages 0-6)

bull Caries Risk Assessment ($1500)

D0601 = Low Risk ) D0602 = Moderate Risk D0603 = High Risk

bull Nutritional counseling D1310 ($4600)

D1310

Additional services such as cleaning fluoride and exam can be rendered based on the risk level

Caries Risk Assessment Bundles

Low risk

Moderate risk

High Risk

CARIES RISK NUTIR TIONAL FIREQUENICY BUNDLIE FIEE ASSESSMENT COUNISELING

($1500) ($4600)

D0601 D1310 6 months $6100

D0602 D1310 4 months $6100

D0603 D1310 3 months $6100

B-PRL-TRN-006AC 32

CalAIM Benefit - Caries Arresting Medicaiment

Silver Diamine Fluoride (SDF) is a covered service available for all ages subject to medical necessity Procedure code 01354 Interim Caries Arres1ing Medicament Application per-tooth the criteria must be met for payment

bull It is paid $12 per tooth

D1354 - Caries Arresting1 Medicament bull Requires a tooth code

bull A benefit

bull For members under age 7

Photograph required

Flexibiinti1es allowed for members under age 4 (per SB 1403)

bull For members age 7 or older in addition to a current i1ntraoral photograph must submit a current diagnostic periapi1cal radiograph and must document the underlying condirtions that exist which indicate that nonrestorative caries treatment i1s optimal

bull D 1354 is a benefit once every six months up to ten teeth per visit for a maximum of four treatments per tooth

B-PRL-TRN-006AC 33

CalAIM lntiative 3 - Continumiddotty of Care

This pay-for-performance payment offers a flat rate payment to dental provider service office locations Fee For Service (FFS) and Safety Net Clinics (SNCs) that maintain dental continuity of care by establishing a dental home for each patient under 21 years of age and perform at least a yearly dental examevaluation for two or more years in a row

Paid at the flat rate of $55 once per year in addition to the SMA This payment will be included in the weekly checkwrite for the FFS delivery system

SNC claims will need to be validated for qualifying codes prior to issuing payment Performance payments are earned and paid to SNC locations once a month

Continuty of Care Example

bull Examevaluation paid for wo or more consecutive years qualifies the service office location for a flat rate performance payment

PAID EXAMEVALUATION CALENDAR YEAR 2021 I CALENDAR YEAR 2022

D0120D0145D0150 X X

B-PRL-TRN-006AC 34

Continuity of Care Dental Codes

bull Service office locations are eligible to earn performance payments on one service performed annually using any of the specified codes depicted below at the flat rate of $55

PROCEDURE CODE PROCEDURE CODE NAME

D0120 Periodic Oral Evaluation - Establliish Patient

ID0145 Oral Evaluation For A Patient Under Three Years Of Age And Counsel ing With Primary Caregiver

D0150 Comprehensive Oral Evaluation - New Or Established Patient

Resources and Forms DHCS website

httpswwwdhcscagovse rvicesPagesD HCS Ca IA IM-Dental aspx

bull Treating Young Kids Everyday (TYKE) training

bull Caries Risk Assessment (CRA) form

bull Attestation form

Questions about CalAIM

dentaldhcsca gov

B-PRL-TRN-006AC 35

0

Requirements for Providers

bull Senate Bill 639 - Effective Jully 1 2020

bull See Bulletin Volume 36 Number 4 (March 2020) Enhanced Protections for Medi-Cal Members

bull Contains provisions regarding lines of credit

bull Requires that dentist provide a written or electronic notice and treatment plan including an itemized llist of treatments and services charged before rendering or incurring costs

Senate Bill 639

bull For all Medi-Cal providers the written treatment plan must indicate if Medi-Cal would cover an alternate medically necessary service It must also notify the IMedi-Cal patient that they have a right to ask for only services covered by Medi-Cal and that the dentist must follow Medi-Cal rules to secure IMedi-Calshycovered services before treatment

Record Keeping Criteria for the Medi-Cal Dental Program

The Surveillance and Utilization Review Subsystem (SURS) department is responsible for overseeing and monitoring the California Medi-Cal Dental Program for suspected fraud abuse and poor quality of care

The goal of the SURS department is to ensure that providers and members are in compliance with the criteria and regulations of the Medi-Cal Dental program and is governed by Title 22 the California Code of Regulations Refer to Section 8 (FRAUD) in the Medi-Cal Dental Provider Handbook for further information


36B-PRL-TRN-006AC

Provider Formsbull TAR Claim Formbull NOAbull RTDbull EOB

6 PATIENT ADDRESS

9

M F-OM AXILLOFACIAL -ORTHODONTIC

SERVICES

1

3

4

5

6

7

8

9

10

2

IM PORTANT NOTEIMPORTANTNOTICE

In order toprocessyour TARClaiman X-rayenvelopecontainingyourradiographsifapplicableMUSTbeattached tothis form TheX-Rayenvelopes (DC-214A and DC-214B) are availablefreeof chargefromthe Denti-CalFormsSupplier

SIGNATURE DATE

SIGNATURE OF PROVIDER OR PERSON AUTHORIZED BY PROVIDER TO BIND PROVIDER BY ABOVE SIGNATURE TOSTATEM ENTS AND CONDITIONS CONTAINED ON THIS FORM

X

DO NOT WRITE IN THIS A RE A

39 THIS IS TO CERTIFY THAT TO THE BEST OF MY KNOWLEDGE THE INFORMATION CONTAINED ABOVE AND ANY ATTACHMENTS PROVIDED IS TRUE ACCURATE AND COMPLETE AND THE REQUESTED SERVICES ARE NECESSARY TO THE HEALTH OF THE PATIENT THE PROVIDER HAS READ UNDERSTANDS AND AGREES TO BE BOUND BY AND COMPLY WITH THE STATEMENTS AND CONDITIONS CONTAINED ON THE BACK OF THIS FORM

DC-217 (R0909)

1 PATIENT NAM E (LASTFIRSTM I) 3 SEXM F

4 PATIENT BIRTHDATEM O DAY YR

5 M EDI-CAL BENEFITS ID NUMBER

7 PATIENT DENTAL RECORD NUM BER

8 REFERRING PROVIDER NUMBERCITY STATE ZIP CODE

CHECK IF YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

P 0 BOX 15610S ACRAME NTO CA 95852-0610P h o n e (800) 423-0507 TREATMENT AUTHORIZATION REQUEST (TAR)CLAIM

RADIOGRAPHS ATTACHED

HOW M ANY_____________

11 CHECK IF

ACCIDENTINJURY

EM PLOYMENT RELATED

13 CHECK IFOTHER DENTAL COVERAGE

14 M EDICARE DENTAL COVERAGE

15 RETROACTIVE ELIGIBILITY (EXPLAIN IN COMMENTS SECTION)

(SEE PROVIDER MANUAL)

16 CHDP CHECK IFCHI LD HEALTH AND

DI SABI LI TY PREVENTI O N

17 CCS CALIFORNIA CHILDREN SERVICES

18 MF-O M AXILLOFACIAL - ORTHODONTIC

SERVICES

10 OTHER ATTACHM ENTS

12 ELIGIBILITY PENDING

(SEE PROVIDER MANUAL)19 BILLING PROVIDER NAME (LASTFIRSTMI) 20 BILLING PROVIDER NUMBER

21 M AILING ADDRESS TELEPHONE NUM BER

CITY STATE ZIP CODE

22 PLACE OF SERVICE HO SPI TAL HO SPI TAL OTHERO FFICE HO ME CLINI C SNF ICF IN- PATI ENT O UT - PATI ENT (PLEASE SPECI FY)1 2 3 4 5 6 7 8

BIC Issue Date ________________

EVC _______________________

EXAM INATION AND TREATM ENT26 TO O TH LTRARCH Q UAD

27 SURFACES

28 DESCRIPTION OF SERVICE( I NCLUDI NG X- RAYS PRO PHYLAXI S M ATERI AL USED ETC )

29 DATE SERVICEPERFORMED

30 Q UANTI TY

31 PROCEDURE

NUMBER

32 FEE

33 RENDERING

PROVIDER NO

34 COM M ENTS 35 TO TAL FEE

CHARG ED

36 PATI ENT SHARE- O F- CO ST

AM O UNT

37 O THER CO VERAG E

AM O UNT

38 DATE BI LLED

wwwdenti -ca lcagov

NOTE AUTHORIZATION DOES NOT GUARANTEE PAYMENTPAYMENT IS SUBJECT TO BENEFICIARYrsquoS ELIGIBILITY AT THE TIME SERVICE IS RENDERED

NOTICE OF AUTHORIZATION

FROMTO PAGE_____OF_____

SIGN ONE COPY AND SEND IT TO DENTI-CAL ndash RETAIN THE OTHER FOR YOUR RECORDS SIGNATURE OF PROVIDER OR PERSON AUTHORIZED BY PROVIDER TO BIND PROVIDER BY ABOVE SIGNATURE TO STATEM ENTS AND CONDITIONS CONTAINED ON THIS FORM

TREATMENT COMPLETED ndash PAYMENT REQUESTEDTHIS IS TO CER TI FY THAT THE INFOR MATI ON C ONTAINED ABOVE AND ANY ATTACHMEN TSPROVIDED IS TRUE ACCURA TE AND C OMPLE TE AND THAT THE PROVI DER HAS READ UNDERSTANDS A ND AGREES TO BE BO UND BY AND C OMP LY WI TH THE STA TEMEN TS ANDCONDITIONS CONTAINED ON THE BACK OF THIS FORM

39

X


34 COMMENTS

PO BOX 15609SACRAMENTO CALIFORNIA 95852-0609Phone 800- 423- 0507

1 BENEFICIARY NAME (LAST FRIST MI)

9RADIOGRAPHS ATTACHED

HOW M ANY _________

10 OTHER ATTACHMENTS

41DELETE

5 BENEFICIARY MEDI-CAL ID NO4 BENEFICIARY BIRTHDATEMO DAY YR

3 SEXM F

7 BENEFICIARY DENTAL RECORD NO

23

16 CHDP

13 OTHER DENTAL COVERAGE11ACCIDENT INJURY

EMPLOYMENT RELATED

27SUR-FACES

28TOOTHNO OR

LETTERARCH

43 ADJREASONCODE

42ALLOWANCE

32FEE

33 RENDERINGPROVIDER NO

31 PROCEDURENUM BER

30QTY

29 DATESERVICE

PERFORMED

44 DATE PROSTHESISORDERED

35 TOTAL FEECHARGED

46 TOTALALLOWANCE

36 BENEFICIARYSHARE-OF-COST

AMOUNT

38 DATEBILLED

37 OTHERCOVERAGE

AMOUNT

YES YES YES

YES

YES

YES

CHECK IF CHECK IF CHECK IF CHECK IF

BIC Issue Date __________________

EVC _________________________

DESCRIPTION OF SERVICE(INCLUDING X-RAYS PROPHYLAXIS MATERIAL USED ETC)

bull ADJUSTMENT CODES - SEE PROVIDER HANDBOOKbull AUTHORIZATION DOES NOT GUARANTEE PAYMENT PAYMENT SUBJECT TO PATIENT ELIGIBILITYbull AUTHORIZED ALLOWANCE MAY BE SUBJECT TO SHARE OF COST OR OTHER COVERAGE DEDUCTIONSbull USE COLUMN 41 TO DELETE SERVICES AUTHORIZED BUT NOT PERFORMED

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

bull FILL IN SHADED AREA AS APPLICABLEbull SIGN AND RETURN FOR PAYMENTbull MULTIPLE - PAGE NOAs MUST BE RETURNED

TOGETHER FOR PAYMENT OR RE-EVALUATIONORIGINA L S IGNA T URE RE QUIRE D

AUTHORIZATION FOR SERVICEBELOW IS

DO NOT WRITE IN THIS AREA

DA T E

26

45 PROSTHESISLINE ITEM

RE-EVALUATION IS REQUESTED YES111413051314

EXPLANATION OF BENEFITS DENTI-CALCALIFORNIA MEDI-CAL DENTAL PROGRAM

PO BOX 15609 SACRAMENTO CA 95852-0609

CHECKNoPROVIDERNo

DATE PAGE NO

STATUS CODE DEFINITIONP = PAIDD = DENIEDA= ADJUSTED

PLEASE CALL (800) 423-0507FOR ANY QUESTIONS REGARDING THIS DOCUMENT

BENEFICIARY NAME MEDI-CALID NO

ADJUDICATED CLAIMS

CLAIMS SPECIFIC NON CLAIMS SPECIFIC

1234567891 00596352

081513 1of 3

Adams James DDS30 Center StreetAnytown CA 95814

CLAIM TOTAL 13200 10100 10100

TOTAL ADJUDICATED CLAIMS 13200 10100 10100

ADJUSTMENT CLAIMS

10100 8500 18600

BC

LINES PRECEDED BY ldquoBrdquo CONTAIN BENEFICIARY INFORMATION

LINES PRECEDED BY ldquoCrdquo CONTAIN CLAIM INFORMATION RELATIVETO ABOVE BENEFICIARY

BENE ID SEX BIRTHDATE

AM OUNTPAID

OTHERCOVERAGE

SHAREOF COST

ALLOWEDAM OUNT

AM OUNTBILLED

REASONCODE

STA-TUS

DATEOF SERVICE

PROCCODE

TOOTHCODE

DOCUM ENTCONTROL NO

AR AMOUNTLEVY AMOUNTADJUSTMENT AMOUNTAMOUNT PAID PAYABLES AMOUNT

B LAST FIRST 99999999D 99999999D M mmddyyC 13163108181 D0150 060113 P 2500 2500 2500 C D0274 060113 P 3000 1800 1800C D0230 060113 P 3000 1800 1800

C D1110 060113 P S019 4700 4000 4000C D1120 060113 D R019 4700 00 00

B LAST FIRST 99999999D 99999999D F mmddyyC 30 NEW OR ADDITIONAL DOCUMENTATION SUBMITTED C 13168101357 15 D7210 061013 A 266B - 9500 - 00 - 00C 14 D2140 061013 A - 5000 - 3900 - 3900C 13 D2140 061013 A - 5000 - 3900 - 3900

CLAIM TOTAL -19500 - 7800 - 7800

B LAST FIRST 99999999D 99999999D F mmddyyC 30 NEW OR ADDITIONAL DOCUMENTATION SUBMITTEDC 13168101357 15 D7210 061013 P 9500 8500 8500C 14 D2140 061013 P 5000 3900 3900C 13 D2140 061013 P 5000 3900 3900

CLAIM TOTAL 19500 16300 16300

TOTAL ADJUSTED CLAIMS 00 8500 8500

PROVIDER CLAIMS TOTAL 13200 18600 18600

PO BOX 15609SACRAMENTO CALIFORNIA 95852-06009Phone 800-423-0507

RESUBMISSION TURNAROUND DOCUMENT

CLAIM TAR NOA

IMPORTANT LISTED IN SECTION ldquo Ardquo ARE ERROR(S) FOUND ON THE CLAIMTARNOA TO FACILITATE PROCESSING TYPE OR PRINT THE CORRECT INFORMATION IN THE CORRESPONDING ITEM IN SECTION ldquoBrdquo SIGN AND DATE FORM AND RETURN SECTION ldquoBrdquo (BOTTOM PORTION) TO DENTI-CAL PLEASE RESPONDPROMPTLY AS PROCESSING CANNOT BE ACCOMPLISHED UNLESS CORRECTIONS ARE RECEIVED BY THE DUE DATE INDICATED FAILURE TO RESPOND WITHINTHE TIME LIMITATION WILL RESULT IN DENIAL OF SERVICES IF YOU HAVE ANY QUESTIONS CALL 800-423-0507 FOR ASSISTANCE OR REFER TO YOURPROVIDER HANDBOOK FOR FURTHER INFORMATION

NOTICEPAGE PAGES

OF

RTD ISSUE DATE RTD DUE DATE

DOCUMENTCONTROL NO

AMOUNTBILLED

BEGINNINGDATE OF SERVICE

PATIENT DENTALRECORD NO

PATIENT MEDI-CALID NUMBERPATIENT NAME

ITEMINFORMATION

BLOCKCLAIMFIELDNO

CLAIMLINE

SUBMITTEDINFORMATION

ERRORCODE

ERROR DESCRIPTION

RETAIN THIS PORTIONDETACH ALONG THIS PERFORATION

DOCUMENT CONTROL NUMBER FOR DENTI-CAL USE ONLY

BILLING PROVIDER NAME

MEDI-CAL PROVIDER NUMBER

PATIENT NAME

PATIENT MEDI-CAL ID NUMBER

This is to certify that the corrected information is true accurate andcomplete and that the provider has read understands and agrees to bebound by and comply w ith the statements and conditions contained onthe back of the form

XSIGNATURE DATE

Signature of provider or person authorized by provider to bind providerby above signature to statements and conditions contained on this form

IF REQUESTED AFFIX POE LABEL(S) IN THIS SPACE THISSPACE MAY BE USED FOR COMMENTS

DENTI-CAL USE ONLY

DCN

SUBMITTED INFORMATION

CLAIMTYPE

PAGE PAGES

OF

CLAIMFIELD NO

CLAIMLINE

ERRORCODE

CORRECTED INFORMATION MUST BEENTERED ON THE SAME LINE AS THEERROR SHOWN IN SECTION ldquoArdquo

CORRECT INFORMATION

RETURN THIS PORTION TO DENTI-CAL PO BOX 15609 SACRAMENTO CA 95852-0609

BILLING PROVIDER NAMEMAILING ADDRESSCITY STATE ZIP CODE

MEDI-CAL PROVIDER NO

01 01

PROCEDURECODE

A

B

37B-PRL-TRN-006AC

6 PATIENT ADDRESS

9

MF-O

MAXILLOFACIAL - ORTHODONTIC

SERVICES

1

3

4

5

6

7

8

9

10

2

IMPORTANT NOTE

IMPORTANT NOTICE

In order to process your TARClaim an X-ray envelope containing your

radiographs if applicable MUST be attached to this form The X-Ray

envelopes (DC-214A and DC-214B) are available free of charge from

the Denti-Cal Forms Supplier

SIGNATURE

DATE

SIGNATURE OF PROVIDER OR PERSON AUTHORIZED BY PROVIDER TO BIND PROVIDER BY ABOVE SIGNATURE TO

STATEMENTS AND CONDITIONS CONTAINED ON THIS FORM

X


39 THIS IS TO CERTIFY THAT TO THE BEST OF MY KNOWLEDGE THE INFORMATION CONTAINED ABOVE AND ANY ATTACHMENTS

PROVIDED IS TRUE ACCURATE AND COMPLETE AND THE REQUESTED SERVICES ARE NECESSARY TO THE HEALTH OF THE

PATIENT THE PROVIDER HAS READ UNDERSTANDS AND AGREES TO BE BOUND BY AND COMPLY WITH THE STATEMENTS

AND CONDITIONS CONTAINED ON THE BACK OF THIS FORM

DC-217 (R0909)

1 PATIENT NAME (LASTFIRSTMI)

3 SEX

M F

4 PATIENT BIRTHDATE

MO DAY YR

5 MEDI-CAL BENEFITS ID NUMBER

7 PATIENT DENTAL RECORD NUMBER

8 REFERRING PROVIDER NUMBER

CITY STATE

ZIP CODE

CHECK IF

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

P0 BOX 15610

SACRAMENTO CA 95852-0610

Phone (800) 423-0507

TREATMENT AUTHORIZATION REQUEST (TAR)CLAIM


HOW MANY_____________

11 CHECK IF

ACCIDENTINJURY

EMPLOYMENT RELATED

13 CHECK IF

OTHER DENTAL COVERAGE

14

MEDICARE DENTAL COVERAGE

15 RETROACTIVE ELIGIBILITY

(EXPLAIN IN COMMENTS SECTION)


16 CHDP CHECK IF

CHILD HEALTH AND

DISABILITY PREVENTION

17 CCS

CALIFORNIA CHILDREN SERVICES

18 MF-O


SERVICES

10

OTHER ATTACHMENTS

12

ELIGIBILITY PENDING


19 BILLING PROVIDER NAME (LASTFIRSTMI) 20 BILLING PROVIDER NUMBER

21 MAILING ADDRESS TELEPHONE NUMBER

CITY STATE ZIP CODE

22 PLACE OF SERVICE HOSPITAL HOSPITAL OTHER

OFFICE HOME CLINIC SNF ICF IN-PATIENT OUT -PATIENT (PLEASE SPECIFY)

1 2 3 4 5 6 7 8

BIC Issue Date ________________

EVC _______________________

EXAMINATION AND TREATMENT

26

TOOTHLTR

ARCHQUAD

27

SURFACES

28 DESCRIPTION OF SERVICE

(INCLUDING X-RAYS PROPHYLAXIS MATERIAL USED ETC)

29

DATE SERVICE

PERFORMED

30

QUANTITY

31

PROCEDURE

NUMBER

32

FEE

33

RENDERING

PROVIDER NO

34 COMMENTS

35

TOTAL FEE

CHARGED

36 PATIENT

SHARE-OF-COST

AMOUNT

37 OTHER

COVERAGE

AMOUNT

38

DATE BILLED

wwwdenti-calcagov

Claim TAR Form (Moving from lsquoLEFT to RIGHTrsquo hellipgo thru all boxeshellip)

BOX 1-5 =The most important info = Pt info (go thru each Box)

1=LAST name First name

3= sex

4= Bdate= modayyr

5= the 14 digit from the ptrsquos BIC Bx 6 ndash Pt address (always use most current)

Bx 7 amp 8 - Optional Bx 9 ndash X-rays Bx 10 ndashAttachments

Bx 11 ndashIn the case of an auto accjob related injury the Beneficiary should use this coverage 1st (DCal would be 2nd coverage)

Bx 12 Elig Pending = fPAuth only - DC canrsquot pay for services until elig is established

Bx 13 lsquoOCovrsquo DCal is always secondary carrier (attach EOB to claim)

Bx 14 Medicare = MCare covers some dental procedures - usually SX procrsquos

- Dentist must be enrolled wMedicare to receive payment from Medicare

- Provrsquos must bill MCare 1st amp attach the lsquoEOMBrsquo they receive to the DCal claim form

Box 15 Retro Elig = Indicate the lsquodatersquo the pt identified themselves as a lsquoMCal ptrsquo in box 34

Box 16 - CHDP Gateway - To age 19 - These benes wbe issued FScope Medi-Cal elig for 2 months while they complete pwork to determine if they qualify for MCal or HFamilies

Box 17 CCS = Underwent major changes effective 7104 All CCS providers must be enrolled in the DCal program All guidelines policies amp procedures for the DCal program will apply to the CCS program This program is to age 21

Box 18 MF-O = All services must be PAuthrsquod except for emergencies MF = Major SX procedures O (Ortho Program)= DCal program also covers lsquoMedically Necessaryrsquo Orthodontia Ortho Prog is to age 21

Provider Information

- The forms come with the Prov Name amp address pre-imprinted with the infolsquoDCalrsquo has on file for your office

- Any chgs to this info must be made in writhing amp must be submitted to the lsquoEnrollment Deptrdquo

Bx 19= Name of practice Bx 20= DCal provider for practice Bx 21= Office address Bx 22 =POS

TX Section

Bx 26= Tooth Code Bx 27= Tsurfaces

Bx 28= Description of service ndash Use lsquostandardizedrsquo abbreviations if using

Bx 29= DOS = Use 8 digits Bx 30= Quantity Bx Bx 31=For dates of service on or after 3108 Use ONLY the CDT-4 procedure codes Bx 32= Use your UCR fees

BOX 33 =

- The Rendering Provider field (Box 33) should always include a Rendering Provider whether your practice is an ldquoIndividualrdquo or ldquoGrouprdquo practice

- This is the lsquopersonalrsquo NPI for the doctor that actually provided that service (on each CSL) to the patient

- Remember that even Rendering Providers MUST be enrolled in the Denti-Cal program BEFORE they start treating Denti-Cal patients

BOX 34 = Comments Box ndash include any doc Pertinent to claim Bx 35= Total Bx 36 =SOC amt incurred (if applies) Bx 37= Amt OC paid (attach EOB from other carrier) Bx 38= Date billed

BOX 39 = Signature Box forms must be signed - No Copies or Rubber Stamps lsquoLive SignrsquoAnyone authorized by Dr may sign lsquoSign your namersquo)

BILLING LIMITATIONS for Claims

-You have 1 year to bill DCal However you must bill within 6 morsquos to receive 100 payment of Denti-Calrsquos SMA If you bill win 7 - 9 morsquos = 75 amp if you bill win 10 - 12 morsquos = 50

- Payment is based on lsquolast day of monthrsquo in which services were performed (per CSL)

image1png

NOTE AUTHORIZATION DOES NOT GUARANTEE PAYMENT

PAYMENT IS SUBJECT TO BENEFICIARYrsquoS ELIGIBILITY AT THE TIME SERVICE IS RENDERED


FROM

TO

PAGE_____OF_____

SIGN ONE COPY AND SEND IT TO DENTI-CAL ndash RETAIN THE OTHER FOR YOUR RECORDS

SIGNATURE OF PROVIDER OR PERSON AUTHORIZED BY PROVIDER TO BIND PROVIDER BY ABOVE SIGNATURE TO STATEMENTS AND CONDITIONS CONTAINED ON THIS FORM

TREATMENT COMPLETED ndash PAYMENT REQUESTED

THIS IS TO CERTIFY THAT THE INFORMATION CONTAINED ABOVE AND ANY ATTACHMENTS PROVIDED IS TRUE ACCURATE AND COMPLETE AND THAT THE PROVIDER HAS READ UNDERSTANDS AND AGREES TO BE BOUND BY AND COMPLY WITH THE STATEMENTS AND CONDITIONS CONTAINED ON THE BACK OF THIS FORM

39

X


34 COMMENTS

PO BOX 15609

SACRAMENTO CALIFORNIA 95852-0609

Phone 800- 423- 0507


9


HOW MANY _________

10

OTHER ATTACHMENTS

41

DELETE

5 BENEFICIARY MEDI-CAL ID NO

4 BENEFICIARY BIRTHDATE

MO DAY YR

3 SEX

M F


23

16 CHDP

13 OTHER DENTAL COVERAGE

11

ACCIDENT INJURY

EMPLOYMENT RELATED

27

SUR-

FACES

28

TOOTH

NO OR

LETTER

ARCH

43 ADJ

REASON

CODE

42

ALLOWANCE

32

FEE

33 RENDERING

PROVIDER NO

31 PROCEDURE

NUMBER

30

QTY

29 DATE

SERVICE

PERFORMED

44 DATE PROSTHESIS

ORDERED

35 TOTAL FEE

CHARGED

46 TOTAL

ALLOWANCE

36 BENEFICIARY

SHARE-OF-COST

AMOUNT

38 DATE

BILLED

37 OTHER

COVERAGE

AMOUNT

YES

YES

YES

YES

YES

YES

CHECK IF

CHECK IF

CHECK IF

CHECK IF

BIC Issue Date __________________

EVC _________________________

DESCRIPTION OF SERVICE


ADJUSTMENT CODES - SEE PROVIDER HANDBOOK

AUTHORIZATION DOES NOT GUARANTEE PAYMENT PAYMENT SUBJECT TO PATIENT ELIGIBILITY

AUTHORIZED ALLOWANCE MAY BE SUBJECT TO SHARE OF COST OR OTHER COVERAGE DEDUCTIONS

USE COLUMN 41 TO DELETE SERVICES AUTHORIZED BUT NOT PERFORMED

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

FILL IN SHADED AREA AS APPLICABLE

SIGN AND RETURN FOR PAYMENT

MULTIPLE - PAGE NOAs MUST BE RETURNED

TOGETHER FOR PAYMENT OR RE-EVALUATION

ORIGINAL SIGNATURE REQUIRED

AUTHORIZATION FOR SERVICE

BELOW IS


DATE

26

45 PROSTHESIS

LINE ITEM

RE-EVALUATION IS REQUESTED YES

111413

051314

Notice of Authorization (NOA)

1 The NOA reflects Allowed Disallowed or Modified procedures

2 DCN

3 lsquoFrom amp To Datersquo = 180 dys

4 4 pieces of patient information from your TAR

5 NOA - is NOT a lsquoguarantee of pmtrsquo (read statement at bottom of NOA)

6 Examples of Modifications

Modifications From DCal

- 3 RCT modified with lsquoRampSrsquo to correct proc Code (explain 270)

- lsquoSrsquo line can be either denied or allowed

Modifications You may make in your office

- Tooth 9 lsquoifrsquo now turns into a SX extraction - lsquotechniquersquo was changed - not the authorized TXhellip Be sure send X-Rrsquos amp additional Doc

Box 33=

- A TXRendering Prov is always required for each dated procedure

- This information goes in Box 33

8 Complete all procedures - DCal can not lsquosplitrsquo the doc

9 Be sure to sign the form when submitting f pmt

Microsoft_PowerPoint_Slidesldx


PAYMENT IS SUBJECT TO BENEFICIARIErsquoS ELIGIBILITY AT THE TIME SERVICE IS RENDERED


FROM

TO

PAGE_____OF_____





39

X


34 COMMENTS

DENTI-CAL

CALIFORNIA MEDI-CAL DENTAL PROGRAM

PO BOX 15609


Phone 800- 423- 0507


9


HOW MANY _________

10

OTHER ATTACHMENTS

41

DELETE



MO DAY YR

3 SEX

M F


23

16 CHDP


11

ACCIDENT INJURY

EMPLOYMENT RELATED

27

SUR-

FACES

28

TOOTH

NO OR

LETTER

ARCH

43 ADJ

REASON

CODE

42

ALLOWANCE

32

FEE

33 RENDERING

PROVIDER NO

31 PROCEDURE

NUMBER

30

QTY

29 DATE

SERVICE

PERFORMED

44 DATE PROSTHESIS

ORDERED

35 TOTAL FEE

CHARGED

46 TOTAL

ALLOWANCE

36 BENEFICIARY

SHARE-OF-COST

AMOUNT

38 DATE

BILLED

37 OTHER

COVERAGE

AMOUNT

YES

YES

YES

YES

YES

YES

CHECK IF

CHECK IF

CHECK IF

CHECK IF

BIC Issue Date __________________

EVC _________________________







1

2

3

4

5

6

7

8

9

10

11

12

13

14

15







BELOW IS


DATE

26

45 PROSTHESIS

LINE ITEM


3 Root Canal Therapy XXXXX D3320 50000 00 R270

3 Root Canal Therapy D3330 50000 33100 S270

3 O AmalgamD2140 5500 3900 355C

9 Extraction - Erupted ToothD7140 5000 4100 355C

U Partial Denture ndash Resin Base 01D5211 40000 25000

LLScaling amp Root Planing XXXXX D4341 5000 00 074B

155500

66100

Adams James DDS 1234567891

30 Center Street (xxx) xxx-xxxx

Anytown CA 95814

Last First x mm dd yy 99999999999999

10318100124

111410

051311

31

B-PRL-TRN-005B



2 DCN









- Tooth 9 lsquoifrsquo now turns into a SX extraction - lsquotechniquersquo was changed - not the authorized TXhellip Be sure send X-Rrsquox amp additional Doc

Box 33=

A TXRendering Prov is always required for each dated procedure

This information goes in Box 33



image2emf

NOTE AUTHORIZATION DOES NOT GUARANTEE PAYMENTPAYMENT IS SUBJECT TO BENEFICIARIErsquoS ELIGIBILITY AT THE TIME SERVICE IS RENDERED


FROMTO

PAGE_____OF_____SIGN ONE COPY AND SEND IT TO DENTI-CAL ndashRETAIN THE OTHER FOR YOUR RECORDS

SIGNATURE OF PROVIDER OR PERSON AUTHORIZED BY PROVIDER TO BIND PROVIDER BY ABOVE SIGNATURE TO STATEMENTS AND CONDITIONS CONT AINED ON THIS FORM

TREATMENT COMPLETED ndashPAYMENT REQUESTED

THISISTOCERTIFYTHATTHEINFORMATIONCONTAINEDABOVEANDANYATTACHMENTSPROVIDEDISTRUEACCURATEANDCOMPLETEANDTHATTHEPROVIDERHASREADUNDERSTANDSANDAGREESTOBEBOUNDBYANDCOMPLYWITHTHESTATEMENTSANDCONDITIONSCONTAINEDONTHEBACKOFTHISFORM

39

X


34 COMMENTS

DENTI-CAL



1 BENEFICIARY NAME (LAST FRIST MI)9


HOW MANY _________


41

DELETE

5 BENEFICIARY MEDI-CAL ID NO4 BENEFICIARY BIRTHDATEMO DAY YR3 SEXM F7 BENEFICIARY DENTAL RECORD NO 2316 CHDP13 OTHER DENTAL COVERAGE

11ACCIDENT INJURYEMPLOYMENT RELATED

27

SUR-FACES

28

TOOTHNO ORLETTERARCH

43 ADJREASONCODE

42ALLOWANCE32FEE

33 RENDERING

PROVIDER NO31 PROCEDURE

NUMBER

30QTY

29 DATESERVICE PERFORMED

44 DATE PROSTHESIS

ORDERED

35 TOTAL FEECHARGED

46 TOTAL

ALLOWANCE

36 BENEFICIARY

SHARE-OF-COST

AMOUNT

38 DATEBILLED

37 OTHERCOVERAGEAMOUNT

YESYESYESYESYESYESCHECK IFCHECK IFCHECK IFCHECK IF

BIC Issue Date __________________EVC _________________________


(INCLUDING X-RAYS PROPHYLAXIS MATERIAL USED ETC)bullADJUSTMENT CODES -SEE PROVIDER HANDBOOKbullAUTHORIZATION DOES NOT GUARANTEE PAYMENT PAYMENT SUBJECT TO PATIENT ELIGIBILITYbullAUTHORIZED ALLOWANCE MAY BE SUBJECT TO SHARE OF COST OR OTHER COVERAGE DEDUCTIONSbullUSE COLUMN 41 TO DELETE SERVICES AUTHORIZED BUT NOT PERFORMED

1

23

4

5

67

8

9101112

13

1415

bullFILL IN SHADED AREA AS APPLICABLEbullSIGN AND RETURN FOR PAYMENTbullMULTIPLE -PAGE NOAs MUST BE RETURNEDTOGETHER FOR PAYMENT OR RE-EVALUATION




DATE

2645 PROSTHESIS

LINE ITEM


3 Root Canal Therapy XXXXX D3320 50000 00 R2703 Root Canal Therapy D3330 50000 33100 S2703 O Amalgam D2140 5500 3900 355C

9 Extraction -Erupted ToothD7140 5000 4100 355CU Partial Denture ndashResin Base01D5211 40000 25000


155500

66100


30 Center Street (xxx) xxx -xxxx

Anytown CA95814


10318100124

111410051311

31

B-PRL-TRN-005B

image1png

EXPLANATION OF BENEFITS

DENTI-CAL



CHECK

No

PROVIDER

No

DATE

PAGE NO

STATUS CODE DEFINITION

P = PAID

D = DENIED

A= ADJUSTED

PLEASE CALL (800) 423-0507

FOR ANY QUESTIONS REGARDING THIS DOCUMENT

BENEFICIARY NAME

MEDI-CAL

ID NO

ADJUDICATED CLAIMS

CLAIMS SPECIFIC

NON CLAIMS SPECIFIC

1234567891

00596352

081513 1

of 3

Adams James DDS

30 Center Street

Anytown CA 95814

CLAIM TOTAL 13200 10100 10100


ADJUSTMENT CLAIMS

10100 8500 18600

B

C


LINES PRECEDED BY ldquoCrdquo CONTAIN CLAIM INFORMATION RELATIVE

TO ABOVE BENEFICIARY

BENE ID

SEX

BIRTH

DATE

AMOUNT

PAID

OTHER

COVERAGE

SHARE

OF COST

ALLOWED

AMOUNT

AMOUNT

BILLED

REASON

CODE

STA-

TUS

DATE

OF SERVICE

PROC

CODE

TOOTH

CODE

DOCUMENT

CONTROL NO

AR AMOUNT

LEVY AMOUNT

ADJUSTMENT AMOUNT

AMOUNT PAID

PAYABLES AMOUNT

B LAST FIRST 99999999D 99999999D M mmddyy

C 13163108181 D0150060113 P 2500 2500 2500

C D0274060113 P 3000 1800 1800

C D0230060113 P 3000 1800 1800

C D1110060113 P S019 4700 4000 4000

C D1120060113 D R019 4700 00 00

B LAST FIRST 99999999D 99999999D F mmddyy

C 30 NEW OR ADDITIONAL DOCUMENTATION SUBMITTED

C 13168101357 15 D7210061013 A 266B - 9500 - 00 - 00

C 14 D2140061013 A - 5000 - 3900 - 3900

C 13 D2140 061013 A - 5000 - 3900 - 3900

CLAIM TOTAL -19500 - 7800 - 7800



C 13168101357 15 D7210 061013 P 9500 8500 8500

C 14 D2140 061013 P 5000 3900 3900

C 13 D2140 061013 P 5000 3900 3900

CLAIM TOTAL 19500 16300 16300



Explanation of Benefits (EOB)

(moving from left to righthellip go over info)

1 Provider info

2 Check

3 EOB lsquodatersquo Very important for CIFrsquos (wersquoll go over CIFrsquos next)

4 Page rsquos of EOB

5 Status Code Definition

6 Adjudicated Claims area = RecipientPatient Info DCN Proc Codes Status Codes Explain lsquoR amp Srsquo

7 The lsquoAdjustment Claimsrsquo section will be discussed in a few minuteshelliphellip

PO BOX 15609


Phone 800-423-0507


CLAIM

TAR

NOA

IMPORTANT LISTED IN SECTION ldquo Ardquo ARE ERROR(S) FOUND ON THE CLAIMTARNOA TO FACILITATE PROCESSING TYPE OR PRINT THE CORRECT INFORMATION

IN THE CORRESPONDING ITEM IN SECTION ldquoBrdquo SIGN AND DATE FORM AND RETURN SECTION ldquoBrdquo (BOTTOM PORTION) TO DENTI-CAL PLEASE RESPOND

PROMPTLY AS PROCESSING CANNOT BE ACCOMPLISHED UNLESS CORRECTIONS ARE RECEIVED BY THE DUE DATE INDICATED FAILURE TO RESPOND WITHIN

THE TIME LIMITATION WILL RESULT IN DENIAL OF SERVICES IF YOU HAVE ANY QUESTIONS CALL 800-423-0507 FOR ASSISTANCE OR REFER TO YOUR

PROVIDER HANDBOOK FOR FURTHER INFORMATION

NOTICE

PAGE PAGES

OF

RTD ISSUE DATE

RTD DUE DATE

DOCUMENT

CONTROL NO

AMOUNT

BILLED

BEGINNING

DATE OF SERVICE

PATIENT DENTAL

RECORD NO

PATIENT MEDI-CAL

ID NUMBER

PATIENT NAME

ITEM

INFORMATION

BLOCK

CLAIM

FIELD

NO

CLAIM

LINE

SUBMITTED

INFORMATION

ERROR

CODE

ERROR DESCRIPTION

RETAIN THIS PORTION

DETACH ALONG THIS PERFORATION




PATIENT NAME


This is to certify that the corrected information is true accurate and

complete and that the provider has read understands and agrees to be

bound by and comply with the statements and conditions contained on

the back of the form

X

SIGNATURE

DATE

Signature of provider or person authorized by provider to bind provider

by above signature to statements and conditions contained on this form

IF REQUESTED AFFIX POE LABEL(S) IN THIS SPACE THIS

SPACE MAY BE USED FOR COMMENTS

DENTI-CAL USE ONLY

DCN


CLAIM

TYPE

PAGE

PAGES

OF

CLAIM

FIELD NO

CLAIM

LINE

ERROR

CODE

CORRECTED INFORMATION MUST BE

ENTERED ON THE SAME LINE AS THE

ERROR SHOWN IN SECTION ldquoArdquo

CORRECT INFORMATION



MAILING ADDRESS

CITY STATE ZIP CODE


01 01

PROCEDURE

CODE

A

B

10

Resubmission Turnaround Document (RTD)

= A computer generated form issued to you when pertinent

info is missing from your Claim TAR NOA

- Letrsquos look at an example of why you might receive an

RTDhelliphelliphellip

image1png

Claims Processing Flow Chart

Input Prep Data Correction File Maintenance

Enrollment Claims Adjudication System BatchAdjudication

Outgoing Mail Customer SupportDocument Control

bull Receives forms from provider

bull Sorts by document type

bull Assigns control numbers

bull Scans documents and attachments

bull Corrects verifies input data

bull Forwards input documents toappropriate data control center(DCC) for further action asdirected by the system

bull Restores discrepancies betweendatabase file information and inputdata

bull Forwards resolved documents toappropriate DCC as directed by the system

bull Enrolls providers into program

bull Updates information in Provider Master File

bull Resolves discrepancies betweenprovider file and input data

bull Forwards documents to appropriateDCC as directed by the system

bull Paraprofessional and professional staffadjudicate via PC using radiographsscanned documents and attachments

bull Forwards documents to appropriate DCC

bull Updates nightly records and stores data processed from that day

bull Transfers claimTAR informationinto recipientrsquos history file

bull Collects payment data for weeklycheck run

bull Generates reports

bull Generates NOAs RTDs CIRsto provider

bull Stores processed document hardcopies according to specific timeframes

bull Files and retains documents awaiting RTD response

bull Maintains files

bull Forwards x-ray envelopes to Recycle or Outgoing Mail for return to provider

bull Uses Phillipsburg equipment whenappropriate to fold documents stuffenvelopes and affix postage

bull Meters x-ray envelopes

bull Communicates with providers viatelephone and written correspondence

bull Researches and responds to providerinquiries

bull Handles provider enrollment andtraining

38B-PRL-TRN-006AC

In administering the California Medi-Cal Dental Program the primary function is to process Claims and Treatment Authorization Requests (TARs) submitted by providers for dental services performed for Medi-Cal members It is the intent of the Medi-Cal Dental program to process documents as quickly and efficiently as possible A description of the processing workflow is offered to promote a better understanding of the Medi-Cal Dental program automated claims system

The TARClaim form and other related documents have been developed to simplify the billing process An introductory packet of billing forms is mailed to all newly enrolled providers so they may begin participating in the Medi-Cal Dental program All billing forms are available from the Medi-Cal Dental forms supplier at no charge to providers

The Medi-Cal Dental Provider Handbook contains detailed step-by-step instructions for completing each of the Medi-Cal Dental forms The handbook also provides a handy checklist to help complete treatment forms accurately

All incoming documents are received and sorted by Gainwell Technology Claims and TARs are separated from other incoming documents and correspondence and then assigned a Document Control Number (DCN) The DCN is a unique 11-digit number that identifies the treatment form throughout the processing system By using the DCN the Medi-Cal Dental program can answer inquiries concerning the status of any treatment form received


39B-PRL-TRN-006AC

THE TREATMENT AUTHORIZATION REQUEST (TAR)CLAIM FORM

The TARClaim form has been developed specifically for the Medi-Cal Dental programProviders can use this form to request authorization of treatment under the Medi-CalDental program or to submit for payment of completed dated services If there is morethan one dentist or dental hygienist alternative practice (RDHAP) at a service officebilling under a single dentistrsquos provider number enter the NPI of the dentist or RDHAPwho performed the service

The dental office must accurately complete the form to insure proper and expeditioushandling by the Medi-Cal Dental program Forms that are incomplete or inaccuratelyfilled out may cause delays in processing andor requests for additional informationPlease ensure the required information is typed or printed clearly To submit theTARClaim form to the Medi-Cal Dental program follow these steps

1 Check the form for completeness Sign and date the form where appropriate

2 Use two separate forms when requesting payment for dated services and priorauthorization of treatment for other services This will expedite reimbursement ofallowable procedures

3 When using forms DC-202 or DC-209 detach page 2 yellow page and retain for thepatients record If using form DC-217 print an additional laser copy for the patientsrecord

4 If required include necessary copies or duplicate radiographsphotos by staplingthem to the corresponding form More information may be found in Section 6 Formsof the Handbook

5 Mail the completed form(s) in the large pre-addressed mailing envelope (DC-206) thatis provided to you free of charge Up to 10 forms with attachments may be mailed ina single document mailing envelope

6 Mail the TARClaim forms to

California Medi-Cal Dental ProgramPO Box 15610Sacramento CA 95852-0610


40B-PRL-TRN-006AC

6 PATIENT ADDRESS

9

MF-OMAXILLOFACIAL - ORTHODONTIC

SERVICES

1

3

4

5

6

7

8

9

10

2

IMPORTANT NOTICEIn order to process your TARClaim an X-ray envelope containing yourradiographs if applicable MUST be attached to this form

SIGNATURE DATE

SIGNATURE OF PROVIDER OR PERSON AUTHORIZED BY PROVIDER TO BIND PROVIDER BY ABOVE SIGNATURE TOSTATEMENTS AND CONDITIONS CONTAINED ON THIS FORM

X



DC-217 (R 1019)

1 PATIENT NAME (LASTFIRSTMI) 3 SEXM F

4 PATIENT BIRTHDATEMO DAY YR



8 REFERRING PROVIDER NPICITY STATE ZIP CODE

CHECK IF YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

P0 BOX 15610SACRAMENTO CA 95852-0610Phone (800) 423-0507 TREATMENT AUTHORIZATION REQUEST (TAR)CLAIM


HOW MANY_____________

11 CHECK IF

ACCIDENTINJURY

EMPLOYMENT RELATED


14 MEDICARE DENTAL COVERAGE


(SEE PROVIDER HANDBOOK)

16 CHDP CHECK IFCHILD HEALTH AND



18 MF-O MAXILLOFACIAL - ORTHODONTIC

SERVICES




19 BILLING PROVIDER NAME (LASTFIRSTMI) 20 BILLING PROVIDER NPI


CITY STATE ZIP CODE

22 PLACE OF SERVICE HOSPITAL HOSPITAL OTHEROFFICE HOME CLINIC SNF ICF IN-PATIENT OUT -PATIENT (PLEASE SPECIFY)

1 2 3 4 5 6 7 8

BIC Issue Date ________________

EVC _______________________

EXAMINATION AND TREATMENT26 TOOTHLTRARCHQUAD

27 SURFACES

28 DESCRIPTION OF SERVICE(INCLUDING X-RAYS PROPHYLAXIS MATERIAL USED ETC)


30 QUANTITY

31 PROCEDURE

NUMBER

32 FEE

33 RENDERING

PROVIDER NPI

34 COMMENTS 35 TOTAL FEE CHARGED

36 PATIENT SHARE-OF-COST

AMOUNT

37 OTHER COVERAGE

AMOUNT

38 DATE BILLED


Address

Address 00000

40900

MM DD YY

X

3

X

Exam MM DD YY D0150 2500 99123456784 Bitewings MM DD YY D0274 2000 9912345678Additional PArsquos MM DD YY 6 D0230 2400 9912345678

8 MIF Composite MM DD YY D2332 15000 99123456785 MOD Amalgam MM DD YY D2160 6500 9912345678

16 Extraction MM DD YY D7140 12500 9912345678

ADAMS JAMES DDS 1234567891

30 CENTER STREET (xxx) xxx-xxxx

ANYTOWN CA 95814

mmddyy

123456789A1

41B-PRL-TRN-006AC

6 PATIENT ADDRESS

9

MF-O


SERVICES

1

3

4

5

6

7

8

9

10

2

IMPORTANT NOTICE


radiographs if applicable MUST be attached to this form

SIGNATURE

DATE



X






DC-217 (R 1019)


3 SEX

M F

4 PATIENT BIRTHDATE

MO DAY YR



8 REFERRING PROVIDER NPI

CITY STATE

ZIP CODE

CHECK IF

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

P0 BOX 15610


Phone (800) 423-0507



HOW MANY_____________

11 CHECK IF

ACCIDENTINJURY

EMPLOYMENT RELATED

13 CHECK IF


14





16 CHDP CHECK IF

CHILD HEALTH AND


17 CCS


18 MF-O


SERVICES

10

OTHER ATTACHMENTS

12

ELIGIBILITY PENDING




CITY STATE ZIP CODE



1 2 3 4 5 6 7 8

BIC Issue Date ________________

EVC _______________________


26

TOOTHLTR

ARCHQUAD

27

SURFACES



29

DATE SERVICE

PERFORMED

30

QUANTITY

31

PROCEDURE

NUMBER

32

FEE

33

RENDERING

PROVIDER NPI

34 COMMENTS

35

TOTAL FEE

CHARGED

36 PATIENT

SHARE-OF-COST

AMOUNT

37 OTHER

COVERAGE

AMOUNT

38

DATE BILLED


Address

Address 00000

40900

MM DD YY

X

3

X

Exam MM DD YY D0150 2500 9912345678

4 Bitewings MM DD YY D0274 2000 9912345678

Additional PArsquos MM DD YY 6 D0230 2400 9912345678

8 MIF Composite MM DD YY D2332 15000 9912345678

5 MOD Amalgam MM DD YY D2160 6500 9912345678

16 ExtractionMM DD YY D7140 12500 9912345678



ANYTOWN CA 95814




3= sex

4= Bdate= modayyr

















TX Section




BOX 33 =






BILLING LIMITATIONS



image1png

When the patient resides in a qualifying facility the following information is required1 Facility address2 Facility name and facility phone number

3 Check box 4 or 5 only on the claim regardless of where the patient is being treated4 If treating patients outside of the facility indicate in box 34 where the patient is actually

being treated ie office hospital

Example of a Facility Claim FormPO BOX 15610SACRAMENTO CALIFORNIA 95852-0610Phone 800-423-0507TREATMENT AUTHORIZATION REQUEST (TAR) CLAIM

3SEXM F

4PATIENT BIRTHDATEMO DAY YR



ZIP CODE 8 REFERRING PROVIDER NPI

1PATIENT NAME (LAST FIRSTMI)

6PATIENT ADDRESS

CITY STATE

9 YESCHECK IF


HOW MANY_____________

YES

11ACCIDENTINJURY

EMPLOYMENT RELATED

CHECK IF YES

YES

YES

13OTHER DENTAL COVERAGE

14MEDICARE DENTAL COVERAGE

15 RETROACTIVE ELIGIBILITY(EXPLAIN IN COMMENTS SECTION)


YES

YES

YES

16

17

18

CHDPCHILD HEALTH AND

DISABILITY PREVENTIONccs



SERVICES

YES

YES

YES



( )CITY STATE ZIP CODE

22 PLACE OF SERVICEOFFICE HOME CLINIC SNF ICF

HOSPITALIN-PATIENT

HOSPITAL OUT-PATIENT

OTHER(PLEASE SPECIFY)

EXAMINATION AND TREATMENT26TOOTHLTRARCHQUAD

28 32FEE

33RENDERING

PROVIDER NPI

CHECK IF CHECK IF

1

3

4

5

6

7

8

9

10

2

34 COMMENTS TOTAL FEECHARGED

36

37

38 DATEBILLED

IMPORTANT NOTEIMPORTANT NOTICEIn order to process your TARClaim an X-ray envelope containingyourradiographs if applicable MUST be attached to this form

SIGNATURE DATE


X



SERVICES

12ELIGIBILITY PENDING


10

OTHER ATTACHMENTS

BIC Issue Date mmddyy

EVC 123456789A1

1 2 3 4 5 6 7 8

DESCRIPTION OF SERVICE(INCLUDING X-RAYS PROPHYLAXIS MATERIALS USED ETC)

27SURFACES

30QUANTITY

31PROCEDURE

NUMBER

29DATE SERVICEPERFORMED

PATIENTSHARE- OF- COST

AMOUNT

35

39 THIS IS TO CERTIFY THAT TO THE BEST OF MY KNOWLEDGE THE INFORMATION CONTAINED ABOVE AND ANY ATTACHMENTS ROVIDED IS TRUE ACCURATE AND COMPLETE AND THE REQUESTED SERVICES ARE NECESSARY TO THE HEALTH OF THE PATIENT THE PROVIDER HAS READ UNDERSTANDS AND AGREES TO BE BOUND BY AND COMPLY WITH THE STATEMENTS AND CONDITIONS CONTAINED ON THE BACK OF THIS FORM

OTHER COVERAGE

AMOUNT


Address

Address 00000

ADAMS JENN DDS 1234567891


ANYTOWN CA 95814

Mary Smith MM DD YY

Prophy MM DD YY D1110 8500 9912345678

8500

MM DD YY

DC-217 (R 1019)

1

1 2

3

4

42B-PRL-TRN-006AC

PO BOX 15610


Phone 800-423-0507

TREATMENT AUTHORIZATION REQUEST (TAR) CLAIM

3SEX

M F

4PATIENT BIRTHDATE

MO DAY YR



ZIP CODE



6PATIENT ADDRESS

CITY STATE

9

YES

CHECK IF


HOW MANY_____________

YES

11

ACCIDENTINJURY

EMPLOYMENT RELATED

CHECK IF

YES

YES

YES

13


14





YES

YES

YES

16

17

18

CHDP

CHILD HEALTH AND


ccs


MF-O


SERVICES

YES

YES

YES

19 BILLING PROVIDER NAME (LASTFIRSTMI)

20 BILLING PROVIDER NPI

21 MAILING ADDRESS

TELEPHONE NUMBER

( )

CITY STATE

ZIP CODE

22 PLACE OF SERVICE

OFFICE HOME CLINIC SNF ICF

HOSPITAL

IN-PATIENT

HOSPITAL

OUT-PATIENT

OTHER

(PLEASE SPECIFY)


26

TOOTHLTR

ARCHQUAD

28

32

FEE

33

RENDERING

PROVIDER NPI

CHECK IF

CHECK IF

1

3

4

5

6

7

8

9

10

2

34 COMMENTS

TOTAL FEE

CHARGED

36

37

38

DATE

BILLED

IMPORTANT NOTE

IMPORTANT NOTICE



SIGNATURE

DATE



X


MF-O


SERVICES

12

ELIGIBILITY PENDING


10

OTHER ATTACHMENTS


EVC 123456789A1

1 2 3 4 5 6 7 8


(INCLUDING X-RAYS PROPHYLAXIS MATERIALS USED ETC)

27

SURFACES

30

QUANTITY

31

PROCEDURE

NUMBER

29

DATE SERVICE

PERFORMED

PATIENT

SHARE- OF- COST

AMOUNT

35


ROVIDED IS TRUE ACCURATE AND COMPLETE AND THE REQUESTED SERVICES ARE NECESSARY TO THE HEALTH OF THE



OTHER

COVERAGE

AMOUNT


Address

Address 00000



ANYTOWN CA 95814

Mary Smith MM DD YY

Prophy MM DD YY D1110 8500 9912345678

8500

MM DD YY

DC-217 (R 1019)

image1png

6 PATIENT ADDRESS

9


SERVICES

1

3

4

5

6

7

8

9

10

2

IMPORTANT NOTE

SIGNATURE DATE


X



DC-217 (R 1019)






CHECK IF YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES



HOW MANY_____________

11 CHECK IF

ACCIDENTINJURY

EMPLOYMENT RELATED









SERVICES






CITY STATE ZIP CODE


1 2 3 4 5 6 7 8

BIC Issue Date ________________

EVC _______________________


27 SURFACES



30 QUANTITY

31 PROCEDURE

NUMBER

32 FEE

33 RENDERING

PROVIDER NPI



AMOUNT

37 OTHER COVERAGE

AMOUNT

38 DATE BILLED


Address

Address 00000

X

9

X


Anytown CA 95814

U Partial Denture ndash Resin Base D5211 40000 L Partial Denture ndash Resin Base D5212 40000

All other treatment has been completedSee attached DC-054 form

80000

MM DD YY

Mary Smith MM DD YY

X



43B-PRL-TRN-006AC

6 PATIENT ADDRESS

9

MF-O


SERVICES

1

3

4

5

6

7

8

9

10

2

IMPORTANT NOTE

SIGNATURE

DATE



X






DC-217 (R 1019)


3 SEX

M F

4 PATIENT BIRTHDATE

MO DAY YR




CITY STATE

ZIP CODE

CHECK IF

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

P0 BOX 15610


Phone (800) 423-0507



HOW MANY_____________

11 CHECK IF

ACCIDENTINJURY

EMPLOYMENT RELATED

13 CHECK IF


14





16 CHDP CHECK IF

CHILD HEALTH AND


17 CCS


18 MF-O


SERVICES

10

OTHER ATTACHMENTS

12

ELIGIBILITY PENDING




CITY STATE ZIP CODE



1 2 3 4 5 6 7 8

BIC Issue Date ________________

EVC _______________________


26

TOOTHLTR

ARCHQUAD

27

SURFACES



29

DATE SERVICE

PERFORMED

30

QUANTITY

31

PROCEDURE

NUMBER

32

FEE

33

RENDERING

PROVIDER NPI

34 COMMENTS

35

TOTAL FEE

CHARGED

36 PATIENT

SHARE-OF-COST

AMOUNT

37 OTHER

COVERAGE

AMOUNT

38

DATE BILLED


Address

Address 00000

X

9

X


Anytown CA 95814

U Partial Denture ndash Resin Base D5211 40000

LPartial Denture ndash Resin BaseD5212 40000

All other treatment has been completed

See attached DC-054 form

80000

MM DD YY

Mary Smith MM DD YY

X

IMPORTANT NOTICE



Now letrsquos look at how to complete a TAR

- TARs have lsquoPriorityrsquo over claims amp TARs are processed within 15 days of receipthellip

- Top filled out same as claimhelliphellipwersquoll move tohellip

- TX section

1 May bill for dated services however no payment will be made till doc Comes back in as NOA lsquoCash-flowrsquo

2 May include full TX plan (procrsquos that do not require PAuth) ndash but must adhere to guidelines amp wait before providing that TX

3 Better to indicate TX plan in Comments lsquoBx 34rsquo

4 Bx 34 - also include any additional doc pertinent to this TAR

5 Be sure to Sign form

image1png

TARCLAIM FORM HELPFUL HINTS and REMINDERS

1 Use only the Current CDT procedure codes Be sure to use all four digits includingthe leading ldquoD

2 Use the quantity column (field 30) when listing multiple procedures with the sameprocedure number

3 When submitting the form for payment of dated services be sure to include therendering provider number in field 33

4 Sign and date the form

5 Staple any necessary attachments (eg operative reports DC-054 Forms andorcopies of radiographsphotos etc) to the back of the form with one staple in theupper right or left corner

6 Use field 34 for any narrative documentation

7 Continuous TARClaim forms and laser forms are not pre-imprinted by the Medi-CalDental program Enter the providers name number and address exactly as itappears on your initial stock of forms

8 If dated services are submitted on a request for authorization they will not be paiduntil the authorized services are paid

9 The Medi-Cal dental program will consider payment for dated services at 100 of theSchedule of Maximum Allowances (SMA) if the form is received within six months ofthe date of service If the form is received within seven to nine months of the date ofservice 75 of the of the SMA will be considered for payment If the claim isreceived within ten to twelve months of the date of service 50 of the SMA will beconsidered for payment

10REFER TO YOUR MEDI-CAL DENTAL PROVIDER HANDBOOK FOR MOREDETAILED INFORMATION ABOUT SUBMITTING THE TARCLAIM FORM


44B-PRL-TRN-006AC

THE NOTICE OF AUTHORIZATION (NOA) FORM

The NOA is a computer-generated form which the Medi-Cal Dental program sends to theprovider following final processing of a TAR The Medi-Cal Dental program will indicateon the NOA whether the requested services are allowed modified or disallowed TheNOA is used either to request payment of authorized services or to request areevaluation of modified or denied services

The NOA will be pre-printed by the Medi-Cal Dental program with the followinginformation

bull Authorization period (the From and To date)bull Member informationbull Provider informationbull Procedures allowed modified andor disallowedbull Allowancebull Adjudication Reason Codes (A list of adjudication codes may be found in section

7 of the Medi-Cal Dental handbook)

The NOA received by the dental office is printed with the same information that wassubmitted on the original TAR Please be sure to verify that the printed information iscorrect prior to completing the form and returning it to the Medi-Cal Dental program

Authorizations are valid for 180 days Once the services have been performed completethe appropriate shaded areas on the NOA sign and date and submit one copy to theMedi-Cal Dental program for payment Retain the other copy for the patients record

Services not requiring prior authorization may be added to the NOA However anyrequired radiographs andor documentation for those procedures must be included

The Medi-Cal Dental program will consider payment of 100 of the Schedule ofMaximum Allowances (SMA) for services rendered if the NOA form is received within sixmonths of the FINAL date of service If the NOA is received within seven to nine monthsof the FINAL date of service 75 of the SMA will be considered for payment And if theNOA is received within ten to twelve months of the FINAL date of service 50 of theSMA will be considered for payment


45B-PRL-TRN-006AC

NOTE AUTHORIZATION DOES NOT GUARANTEE PAYMENTPAYMENT IS SUBJECT TO MEMBERrsquoS ELIGIBILITY AT THE TIME SERVICE IS RENDERED



SIGN ONE COPY AND SEND IT TO DENTI-CAL ndash RETAIN THE OTHER FOR YOUR RECORDS SIGNATURE OF PROVIDER OR PERSON AUTHORIZED BY PROVIDER TO BIND PROVIDER BY ABOVE SIGNATURE TO STATEMENTS AND CONDITIONS CONTAINED ON THIS FORM

TREATMENT COMPLETED ndash PAYMENT REQUESTEDTHIS IS TO CERTIFY THAT THE INFORMATION CONTAINED ABOVE AND ANY ATTACHMENTSPROVIDED IS TRUE ACCURATE AND COMPLETE AND THAT THE PROVIDER HAS READUNDERSTANDS AND AGREES TO BE BOUND BY AND COMPLY WITH THE STATEMENTS ANDCONDITIONS CONTAINED ON THE BACK OF THIS FORM

39

X


34 COMMENTS


1 MEMBER NAME (LAST FRIST MI)


HOW MANY _________


41DELETE


3 SEXM F


23

16 CHDP


EMPLOYMENT RELATED

27SUR-FACES

28TOOTHNO OR

LETTERARCH

43 ADJREASON

CODE42ALLOWANCE

32FEE


31 PROCEDURENUMBER

30QTY

29 DATESERVICE

PERFORMED


35 TOTAL FEECHARGED

46 TOTALALLOWANCE


AMOUNT

38 DATEBILLED

37 OTHERCOVERAGE

AMOUNT

YES YES YES

YES

YES

YES


BIC Issue Date __________________

EVC _________________________


bull WHEN APPLICABLE ALL SERVICES SUBMITTED FOR MEMBERS UNDER 21 YEARS OF AGE HAVE BEEN EVALUATED FOR EPSDT CRITERIAbull ADJUSTMENT CODES - SEE PROVIDER HANDBOOKbull AUTHORIZATION DOES NOT GUARANTEE PAYMENT PAYMENT SUBJECT TO PATIENT ELIGIBILITYbull AUTHORIZED ALLOWANCE MAY BE SUBJECT TO SHARE OF COST OR OTHER COVERAGE DEDUCTIONSbull USE COLUMN 41 TO DELETE SERVICES AUTHORIZED BUT NOT PERFORMED

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15


TOGETHER FOR PAYMENT OR RE-EVALUATIONORIGINAL SIGNATURE REQUIRED



DATE

26



3 Root Canal Therapy XXXXX D3320 50000 00 R2703 Root Canal Therapy D3330 50000 33100 S2703 O Amalgam D2140 5500 3900 355C9 Extraction - Erupted Tooth D7140 5000 4100 355C

U Partial Denture ndash Resin Base 01 D5211 40000 25000LL Scaling amp Root Planing XXXXX D4341 5000 00 081

15550066100

Adams James DDS 123456789130 Center Street (xxx) xxx-xxxxAnytown CA 95814


YY318100124

1114YY0513YY

46B-PRL-TRN-006AC


PAYMENT IS SUBJECT TO MEMBERrsquoS ELIGIBILITY AT THE TIME SERVICE IS RENDERED


FROM

TO

PAGE_____OF_____





39

X


34 COMMENTS

PO BOX 15609


Phone 800-423-0507


9


HOW MANY _________

10

OTHER ATTACHMENTS

41

DELETE



MO DAY YR

3 SEX

M F


23

16 CHDP


11

ACCIDENT INJURY

EMPLOYMENT RELATED

27

SUR-

FACES

28

TOOTH

NO OR

LETTER

ARCH

43 ADJ

REASON

CODE

42

ALLOWANCE

32

FEE

33 RENDERING

PROVIDER NO

31 PROCEDURE

NUMBER

30

QTY

29 DATE

SERVICE

PERFORMED

44 DATE PROSTHESIS

ORDERED

35 TOTAL FEE

CHARGED

46 TOTAL

ALLOWANCE

36 BENEFICIARY

SHARE-OF-COST

AMOUNT

38 DATE

BILLED

37 OTHER

COVERAGE

AMOUNT

YES

YES

YES

YES

YES

YES

CHECK IF

CHECK IF

CHECK IF

CHECK IF

BIC Issue Date __________________

EVC _________________________



WHEN APPLICABLE ALL SERVICES SUBMITTED FOR MEMBERS UNDER 21 YEARS OF AGE HAVE BEEN EVALUATED FOR EPSDT CRITERIA





1

2

3

4

5

6

7

8

9

10

11

12

13

14

15







BELOW IS


DATE

26

45 PROSTHESIS

LINE ITEM




3 O AmalgamD2140 5500 3900 355C



LLScaling amp Root Planing XXXXX D4341 5000 00 081

155500

66100



Anytown CA 95814


YY318100124

1114YY

0513YY



2 DCN










Box 33=





image1png

REEVALUATION REQUEST

Reevaluation of a modified or denied treatment plan may be requested The reevaluation request must be received by the Medi-Cal Dental program on or prior to the expiration date To request reevaluation follow these steps

1 Check the box marked ldquoREEVALUATION REQUESTEDrdquo in the upper right corner of the NOA

2 DO NOT SIGN THE NOA

3 Include new or additional documentation and enclose radiographs as necessary

4 Return the NOA toCalifornia Medi-Cal Dental ProgramPO Box 15609Sacramento CA 95852-0609

After reevaluation a new NOA will be sent to your office


47B-PRL-TRN-006AC

NOAHELPFUL HINTSREMINDERS

1 Providers must wait until the NOA is received from the Medi-Cal Dental program before providing services that require prior authorization

2 DO NOT attach a CIF when requesting a reevaluation

3 Return all upper pages of a multi-page NOA at the same time

4 Include the rendering provider number in field 33 of the NOA

5 Sign and date the NOA when submitting for payment

6 REMINDER Authorization does not guarantee payment Payment is subject to a memberrsquos eligibility More information can be found in Section 6 Forms of the Handbook

EXAMPLE OF NOA


48B-PRL-TRN-006AC

RESUBMISSION TURNAROUND DOCUMENT (RTD)

The RTD is a computer-generated form sent to request missing or additional informationneeded to completely process the claim TAR or NOA

The RTD consists of two sections Section ldquoArdquo and Section ldquoBrdquo The top portion ldquoArdquo ofthe RTD indicates the associated DCN and lists the error(s) found on the originaldocument Section ldquoArdquo also indicates the return due date The provider has 45 days torespond to the RTD Retain Section ldquoArdquo for the office records Section ldquoBrdquo indicates theassociated DCN lists the error(s) found on the original document and provides space toenter the requested information

1 To ensure the RTD is properly processed follow these steps

2 Sign and date the RTD If the RTD is returned unsigned the requested informationcannot be used to process the original claim TAR or NOA

3 Return all pages of a multi-page RTD in one envelope

4 Return the RTD promptly If the RTD is not received by the Medi-Cal Dentalprogram within the 45-day time limitation the Medi-Cal Dental program must denythe original claim TAR or NOA

5 Return the RTD to


More information may be found in Section 6 Forms of the Handbook


49B-PRL-TRN-006AC

50B-PRL-TRN-006AC

_vn 1vnr

GJ T AR

- rrullENT

NOA

I Medi-Cal Dental 1-U tJP l ~ GUt

SACRAM E NTO CA LI FORNI A S5852-0G00S

Pn o n e 800423 -0 507 lt -- C~~M

~ bull- ISTEO l iNSECTION -A-ARE ERRORtS) FOUNO 0N - - middot - bullbull ffARENOA TOFACIL ITAT E PROCESSI G TYPEOR PRI ry- THECORRECT I FOiWAT IO I T tl E CORRESP _ m DATE Faat A D RE TU SECTION 70 - i80TTOM PORTION) TOM EOI-CAL OE T Al PLEASE RfSPO D PROMPTLY AS PROCESSI G CANNOT 18[ ACCOMPLISHED UNl ESS CORRECTIONS ARpound RiECEIVCO BY T I OUE DATE IN DICAT IEO fAJ l URE T ORLSPOND WIT H] TtlE T HAE l lM IT ATIONW IL LRpoundStn T I OE JAL OF SERVICES I FYOO HAVE AflYOUESTIONS CAL L SOCl -~23 -05(17 FORASSIST AINCE ORIRpound FER TO YOUR PROVIOfUIANOBOOK FOR IFURTtlER I FCgtru4 ATION

Bil l I G PROVIDER NAME

M AJ l I G ADDRpoundSS CIT Y S T ATE ZIP CODE

Ad ams James DDS

M EOI-CAL PROVJOER NO

1234567899 NOTICE

PAGE m__ OF I

01 01

30 Center Street ~ T d d -~ d d ~ ~ -----=A=nvt=o~wnwCA9~58~14 ----rPATil~ml-Ot- FiillTw ~-iiEGiiooltil rnn-=YY=l==inll~7

- loo I PATIENT 14 EDI-CAL PATl rnT OEHAL BEGINNJ~G ~ PAT E T N~M E 10 l4 BER RiECORO 0 DAT E or SERVICE BILL ED OONT ROl 0

ITE

Last First

I FORMATION BLOCgt(

26 2 39

999999990

SUSM ii ED NFORUAT ON

P OCEOU E E 0

CO OE CO OE

07140 51 52

662 00 YY297102350

EAAOR OESCIU PTIOl

Procedure requires tooth code Signature missing or invalid Sign RTD

OOCUl4 E T CONTROi UM BER middot r ORl4rnl CAL DENT AL DENTI-C~ USEONLY CORRE CTE0 I FOiW AT IDN M U S T BE

USE Oily YY29 7102350 ~ 01ltgt 0 IE T [Rpound0 oN THE SAM [ l I E AS H I E

ERROR SHOW I SECT I ON1 A-_

BllllNG IPROVl OER NA14 E

Adams James DDS M EOI-CAL PROVIDER HUM tBER

1234567899 PATICINT NAit I[

Last First PATIENT 14 EDI-CAL 10 NlJl4 MR

T h is is o rmif lh i h e w mc c d iricm1o1 1Dn is111 e c w a le n d C a m p l e ~ r1dlhJII poiiU- htsruid IJl CieHSn~ bullbull middotud i g e e la b e b ou n d b y -Ti d w rTlJI wi lh lhs tt lm aertsirdc md forrco1 ai i aI 01 l h e b t cl d I bullfa m

x NNDD YY DATE

S i9 n1 1urea l praj d u u Flrul 11l1u i 41dtyen POldu l atind p ali cb r b i tbaw ign 11re 1a s l lurxt n s i rtl tu1 d l Drtc cr111i rn d 01 1h i f amL

I f REOlJEST EO AfFIX P OE L ABEL (S) I THIS SPACE Tm s SPACE MAY BE USEO IFOR COMMpound T S

SUB 141TTEO I FORl4 A TIOl

26 04 ~

39 52

CORRE CT INFORMA TI ON LL I I TT I -r

I B I _

I_J ) ~-4--4--+--+--------------i

~ _____ _ RE nJRN THIS P ORTl O N TO MED I-CAL DENTA L P O B OX 15609 SA CRA ME NW CA 95852-0609

THE EXPLANATION OF BENEFITS (EOB)The EOB is a computer-generated statement that accompanies each Medi-Cal Dentalpayment It lists all paid modified and denied claims which have been processed duringthe payment cycle as well as adjusted claims and claims and TARs which haveremained ldquoin processrdquo for more than 18 days The EOB also shows non-claims-specifiedinformation such as payablereceivable amounts and levy deductions EOBs arenormally issued weekly

Following is an explanation of each item shown on the sample EOB1 The Memberrsquos Information This line is preceded by an ldquoBrdquo for ldquoBeneficiary

(member)rdquo

2 Claim information for the listed member This line is preceded by a ldquoCrdquo for ldquoClaimrdquo

3 Provider Number The National Provider Identifier (NPI) number that was issuedby NPPES to a provider for their type of business

4 Provider Name and Address The providerrsquos name and billing address

5 Check Number The number of the check issued with the EOB

6 Date The date the EOB was issued

7 Page Number The page number(s) of the EOB

8 Status Code Definition The list of each status code used to identify a claim lineand explanation of what each code means

9 Member Name The name of the member last name first name and middle initialEach member is listed individually

10Medi-Cal ID Number The number issued to the member by Medi-Cal and shownon the BIC (only the first nine digits will appear on the EOB)

11Member ID The memberrsquos ID number

12Sex The sex of the member

13Birth Date The memberrsquos date of birth

14Document Control Number The identifying number assigned to each claimreceived by the Medi-Cal Dental program


51B-PRL-TRN-006AC

15 Tooth Code The tooth number or letter arch code or quadrant listed to help identify the procedure(s) reported on the EOB

16 Procedure Code The code listed on a claim line identifying each service performed This code may differ from the procedure code submitted on the claim because of modification of the procedure by a Medi-Cal Dental professional or paraprofessional to comply with the criteria manual and successfully process the claim

17 Date of Service The date the service was performed

18 Status Identifies the status of each claim line (See item 8 for a list of status codes and their definitions)

19 Reason Code Explains why a claim line was either denied modified altered or paid at an amount other than billed

20 Amount Billed The amount billed for each claim line

21 Allowed Amount The amount allowed by the Medi-Cal Dental program for each claim line This amount is the lesser of the billed amount and maximum amount allowed by the SMA

22 Share of Cost The amount the member paid toward a Share of Cost

23 Other Coverage The amount paid by Medicare or any other insurance carrier

24 Amount Paid The total amount paid to a provider after any applicable deductions shown in item 22 and 23

25 Claims Specific The total amounts of all paid and adjusted claims listed on the EOB

26 Non-Claims Specific The total payable amounts levy amounts and receivable amounts listed on the EOB if applicable This information is printed on the last page of the EOB

27 Check Amount The amount of the check that accompanies the EOB


52


B-PRL-TRN-006AC

EXPLANATION OF BENEFITSDENTI-CAL

CALIFORNIA MEDI-CAL DENTAL PROGRAMPO BOX 15609 SACRAMENTO CA 95852-0609

CHECKNoPROVIDER

No



BENEFICIARY NAME MEDI-CALID NO SEX

ADJUDICATED CLAIMS


AMOUNT PAID PAYABLES AMOUNT LEVY AMOUNT AR AMOUNT CHECK AMOUNT



1234567899 00596352


B LAST FIRST 99999999D 99999999D M mmddyyC YY163108181 D0150 0601YY P 2500 2500 2500 C D0274 0601YY P 3000 1800 1800C D0230 0601YY P 3000 1800 1800C D1120 0601YY D R019 4700 00 00C D1110 0601YY P S019 4700 4000 4000

CLAIM TOTAL 13200 10100 10100


ADJUSTMENT CLAIMS

B LAST FIRST 99999999D 99999999D F mmddyyC 30 NEW OR ADDITIONAL DOCUMENTATION SUBMITTEDC YY168101357 15 D7210 0610YY A 266B - 9500 - 00 - 00C 14 D2140 0610YY A - 5000 - 3900 - 3900C 13 D2140 0610YY A - 5000 - 3900 - 3900

CLAIM TOTAL - 19500 - 7800 - 7800

B LAST FIRST 99999999D 99999999D F mmddyyC 30 NEW OR ADDITIONAL DOCUMENTATION SUBMITTEDC YY168101357 15 D7210 0610YY P 9500 8500 8500C 14 D2140 0610YY P 5000 3900 3900C 13 D2140 0610YY P 5000 3900 3900

CLAIM TOTAL 19500 16300 16300



10100 8500 18600

DATE 0606YY PAGE NO 3of 3

1

2

3

4

5

6 7

8

9 10 11 12 13

14 15 16 17 18 19 20 21 22 23 24

25 26 27

BC STA-

TUSDATE

OF SERVICEPROCCODE

TOOTHCODE

DOCUMENTCONTROL NO

AMOUNTPAID

OTHERCOVERAGE

SHAREOF COST

ALLOWEDAMOUNT

AMOUNTBILLED

REASONCODE

BENE ID BIRTHDATE

ADJUSTMENT AMOUNT

53B-PRL-TRN-006AC


DENTI-CAL



CHECK

No

PROVIDER

No


P = PAID

D = DENIED

A= ADJUSTED

PLEASE CALL (800) 423-0507


BENEFICIARY NAME

MEDI-CAL

ID NO

SEX

ADJUDICATED CLAIMS

CLAIMS SPECIFIC

NON CLAIMS SPECIFIC

AMOUNT PAID

PAYABLES AMOUNT

LEVY AMOUNT

AR AMOUNT

CHECK AMOUNT




1234567899

00596352

Adams James DDS

30 Center Street

Anytown CA 95814

B LAST

FIRST

99999999D 99999999D M mmddyy

C YY163108181 D0150

0601YY P

2500 2500

2500

C

D0274

0601YY P

3000 1800 1800

C

D0230

0601YY P

3000 1800

1800

C

D1120

0601YY

D R019

4700

00 00

C D1110

0601YY P S019

4700 4000

4000

CLAIM TOTAL

13200

10100

10100

TOTAL ADJUDICATED CLAIMS

13200 10100

10100

ADJUSTMENT CLAIMS

B LAST FIRST

99999999D 99999999D F mmddyy


C YY168101357 15 D7210

0610YY A 266B - 9500 - 00

- 00

C

14 D2140

0610YY A - 5000 - 3900 - 3900

C

13 D2140

0610YY A - 5000 - 3900 - 3900

CLAIM TOTAL - 19500 - 7800 - 7800

B LAST FIRST

99999999D 99999999D F mmddyy


C YY168101357 15 D7210

0610YY P 9500 8500 8500

C

14 D2140

0610YY P 5000 3900 3900

C

13 D2140

0610YY P 5000 3900 3900

CLAIM TOTAL 19500 16300 16300


PROVIDER CLAIMS TOTAL

13200

18600 18600

10100 8500 18600

DATE 0606YY PAGE NO 3

of 3

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

B

C

STA-

TUS

DATE

OF SERVICE

PROC

CODE

TOOTH

CODE

DOCUMENT

CONTROL NO

AMOUNT

PAID

OTHER

COVERAGE

SHARE

OF COST

ALLOWED

AMOUNT

AMOUNT

BILLED

REASON

CODE

BENE ID

BIRTH

DATE

ADJUSTMENT AMOUNT



CHECKNoPROVIDER

No

DATE 0606YY PAGE NO 3of 3STATUS CODE DEFINITION

P = PAIDD = DENIEDA= ADJUSTED



BENE ID SEXBIRTHDATE

AMOUNTPAID

ALLOWEDAMOUNT

CLAIMS SPECIFIC NON CLAIMS SPECIFICAMOUNT PAID ADJUSTMENT AMOUNT PAYABLES AMOUNT LEVY AMOUNT AR AMOUNT CHECK AMOUNT

LINES PRECEDED BY ldquoRrdquo CONTAIN BENEFICIARY INFORMATION


005963521234567899


DOCUMENTS IN-PROCESSLAST NAME FIRST NAME MEDI-CAL ID BENE ID DOB DCN AMT BILLED CODE----------------------------------------------------------------------------------------------------------------------------------------------------------------------LAST FIRST 99999999D 99999999D mmddyy YY168108150 56700 C IRLAST FIRST 99999999D 99999999D mmddyy YY169103850 42300 T CSLAST FIRST 99999999A 99999999A mmddyy YY175100684 11200 C IR

TOTAL DOCUMENTSIN-PROCESS 3 TOTAL BILLED 110200

THE FOLLOWING LEGEND HAS BEEN INCLUDED FOR IN-PROCESS STATUS CODES----------------------------------------------------------------------------------------------------------------------------------------------------------------------

C = CLAIM N = NOA T = TAR R = TAR REEVALUATION

DV - DATA VALIDATION (DOCUMENT IS AWAITING REVIEW OF KEYED DATA AGAINSTDOCUMENT INFORMATION)

IR - INFORMATION REQUIRED (AN RTD FOR ADDITIONAL INFORMATION OR AN EDI REQUESTFOR XRAYSATTACHMENTS WAS SENT TO PROVIDER)

RV - RECIPIENT VERIFICATION (DOCUMENT IS AWAITING VALIDATION OF RECIPIENT INFO)PV - PROVIDER VERIFICATION (DOCUMENT IS AWAITING VALIDATION OF PROVIDER INFO)PR - PROFESSIONAL REVIEW (DOCUMENT IS SCHEDULED FOR PROFESSIONAL REVIEW)CS - CLINICAL SCREENING (DOCUMENT IS SCHEDULED FOR CLINICAL SCREENING REVIEW)SR - STATE REVIEW (DOCUMENT IS SCHEDULED FOR REVIEW BY STATE STAFF)

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++THE NEXT SCHEDULED BASIC SEMINAR WILL BE HELD IN ANYTOWNON MMDDYY FROM 830 AM TO 1130 AM PLEASE CALL (800) 423-0507FOR RESERVATIONS

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++THE NEXT SCHEDULED ADVANCED SEMINAR WILL BE HELD IN ANYTOWNON MMDDYY FROM 800 AM TO 1200 PM PLEASE CALL (800) 423-0507FOR RESERVATIONS

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++THE NEXT SCHEDULED WORKSHOP SEMINAR WILL BE HELD IN ANYTOWNON MMDDYY FROM 830 AM TO 330 PM PLEASE CALL (800) 423-0507FOR RESERVATIONS

BC DOCUMENT

CONTROL NOOTHER

COVERAGESHARE

OF COSTAMOUNTBILLED

REASONCODE

STA-TUS

DATEOF SERVICE

PROCCODE

TOOTHCODE

54B-PRL-TRN-006AC

OTHER

COVERAGE

SHARE

OF COST

AMOUNT

BILLED

REASON

CODE

STA-

TUS

DATE

OF SERVICE

PROC

CODE

TOOTH

CODE


DENTI-CAL



CHECK

No

PROVIDER

No


of 3


P = PAID

D = DENIED

A= ADJUSTED

PLEASE CALL (800) 423-0507


BENEFICIARY NAME

MEDI-CAL

ID NO

BENE ID

SEX

BIRTH

DATE

AMOUNT

PAID

ALLOWED

AMOUNT

CLAIMS SPECIFIC

NON CLAIMS SPECIFIC

AMOUNT PAID

ADJUSTMENT AMOUNT

PAYABLES AMOUNT

LEVY AMOUNT

AR AMOUNT

CHECK AMOUNT




00596352

1234567899

Adams James DDS

30 Center Street

Anytown CA 95814

DOCUMENTS IN-PROCESS

LAST NAME FIRST NAME MEDI-CAL ID BENE ID DOB DCN AMT BILLED CODE

----------------------------------------------------------------------------------------------------------------------------------------------------------------------

LAST FIRST99999999D 99999999D mmddyyYY168108150 56700 CIR

LAST FIRST 99999999D 99999999D mmddyyYY169103850 42300 TCS

LAST FIRST 99999999A 99999999A mmddyyYY175100684 11200 CIR


THE FOLLOWING LEGEND HAS BEEN INCLUDED FOR IN-PROCESS STATUS CODES

----------------------------------------------------------------------------------------------------------------------------------------------------------------------


DV - DATA VALIDATION (DOCUMENT IS AWAITING REVIEW OF KEYED DATA AGAINST

DOCUMENT INFORMATION)

IR - INFORMATION REQUIRED (AN RTD FOR ADDITIONAL INFORMATION OR AN EDI REQUEST

FOR XRAYSATTACHMENTS WAS SENT TO PROVIDER)

RV - RECIPIENT VERIFICATION (DOCUMENT IS AWAITING VALIDATION OF RECIPIENT INFO)

PV - PROVIDER VERIFICATION (DOCUMENT IS AWAITING VALIDATION OF PROVIDER INFO)

PR - PROFESSIONAL REVIEW (DOCUMENT IS SCHEDULED FOR PROFESSIONAL REVIEW)

CS - CLINICAL SCREENING (DOCUMENT IS SCHEDULED FOR CLINICAL SCREENING REVIEW)

SR - STATE REVIEW (DOCUMENT IS SCHEDULED FOR REVIEW BY STATE STAFF)

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

THE NEXT SCHEDULED BASIC SEMINAR WILL BE HELD IN ANYTOWN

ON MMDDYY FROM 830 AM TO 1130 AM PLEASE CALL (800) 423-0507

FOR RESERVATIONS

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

THE NEXT SCHEDULED ADVANCED SEMINAR WILL BE HELD IN ANYTOWN

ON MMDDYY FROM 800 AM TO 1200 PM PLEASE CALL (800) 423-0507

FOR RESERVATIONS

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

THE NEXT SCHEDULED WORKSHOP SEMINAR WILL BE HELD IN ANYTOWN


FOR RESERVATIONS

B

C

DOCUMENT

CONTROL NO

UNKNOWN-0

Provider InquiriesClaim Inquiry Forms

55B-PRL-TRN-006AC

THE CLAIM INQUIRY FORM (CIF)

Submitting a CIF enables the Medi-Cal Dental program to give an automated fast responseto an inquiry The dental office should use the CIF for two reasons

1 Inquire about the status of a TAR or Claima) The Medi-Cal Dental program will respond to a CIF with a Claim Inquiry

Response (CIR)2 Request reevaluation of a modified or denied claim or NOA for payment

CIF TRACER Is used to request the status of a claim or TAR

Providers should wait one month before submitting a CIF Tracer to allow enough time for thedocument to be processed If after one month the claim or TAR has not been processed orhas not appeared in the Documents In Process section of the EOB a CIF Tracer should besubmitted

CLAIM REEVALUATION Is used to request the reevaluation of a modified or denied claimor NOA

If a provider wishes to have a processed claim or NOA that has appeared on the EOBreevaluated a CIF Reevaluation should be submitted The CIF must be submitted within 6months of the date on the EOB DO NOT re-bill on a claim form

To submit a CIF to Denti-Cal follow these steps

1 Use a separate CIF for each inquiry2 Check only one inquiry reason box on each CIF3 Complete all applicable areas4 Sign and date5 Attach all related radiographsphotos6 DO NOT USE THE CIF TO REQUEST A FIRST LEVEL APPEAL7 Mail to


Inquiries using the CIF are limited to those reasons indicated on the form Any other type ofinquiry or request should be handled by telephone or written correspondence Prior tosubmitting a CIF please contact the telephone service center (TSC) at (800) 423-0507 withany inquiries

All radiographsphotos submitted with a CIF must be stapled to the back of thecorresponding CIF More information may be found in Section 6 Forms of the Handbook

56


B-PRL-TRN-006AC

USE THIS FORM FOR ONE CLAIM OR TREATMENT AUTHORIZATION REQUEST ONLY

CLAIM INQUIRY FORM

BILLING PROVIDER NAME MEDI-CAL PROVIDER NUMBER

MAILING ADDRESS TELEPHONE NUMBER


Before submitting a CIFbull Allow one month for the status of the document to appear on your

Explanation of Benefits (EOB)bull Type or print all informationbull Use the appropriate x-ray envelope and attach to this form bull See your Provider Handbook for detailed instructions bull For clarification call DENTI-CAL

PATIENT NAME (LAST FIRST MI)

PATIENT MEDI-CAL ID NUMBER PATIENT DENTAL RECORD NUMBER (OPTIONAL)

INQUIRY REASON - CHECK ONLY ONE BOX

REMARKS (Corrections or Additional information)


XSIGNATURE DATE


FOR DENTI-CAL USE ONLY

OPER ID ______________________________________

ACTION CODE ___________________________________

IMPORTANT

DOCUMENT CONTROL NUMBER (NECESSARY FOR RE-EVALUATION)

DATE BILLED

CITY STATE ZIP CODE

Please advise status of

Claim for Payment Attach a copy of formDate of Service_______________________Treatment Authorization Request (TAR) Attach a copy of form

CLAIMTAR TRACER ONLY CLAIM RE-EVALUATION ONLY

Please re-evaluate modificationdenial of claimfor payment I have attached all necessaryradiographs andor documentation


Anytown CA 95814

Last First

99999999999999 MM DD YY

X

Please research claim for DOS MM DD YY- we have norecord of payment Thank you

30 Center Street (XXX) XXX-XXXX

MM DD YY

Mary Jones MM DD YY

57

CORRESPONDENCE REFERENCE NUMBER FOR MEDII-CAL DENTAL USE ONLY

CLAIM INQUIRY RESPONSE

POBOX 15609 SACRAMENTO CALIFORNIA 95852Phone (800) 423-0507

PATIENT NAME DOCUMENT CONTROL NO

PATIENT MEDI-CAL ID NO PATIENT DENTAL RECORD NUMBER DATE BILLED

IN RESPONSE TO YOUR MEDI-CAL DENTAL INQUIRY

STATUS CODE EXPLANATION

ADDITIONAL EXPLANATION

YY30900132

Adams James DDS 123456789930 Center Street (XXX) XXX-XXXXAnytown CA 95814

Last First99999999D MM DD YY

01 CLAIM NEVER RECEIVED PLEASE SUBMIT NEW CLAIM

7AW MM DD YYBY DATE

B-PRL-TRN-006AC


CLAIM INQUIRY FORM



PO BOX 15609


Phone 800-423-0507

Before submitting a CIF

Allow one month for the status of the document to appear on your


Type or print all information

Use the appropriate x-ray envelope and attach to this form

See your Provider Handbook for detailed instructions

For clarification call DENTI-CAL





THIS IS TO CERTIFY THAT THE INFORMATION CONTAINED ABOVE AND ANY ATTACHMENTS

PROVIDED IS TRUE ACCURATE AND COMPLETE AND THAT THE PROVIDER HAS READ

UNDERSTANDS AND AGREES TO BE BOUND BY AND COMPLY WITH THE STATEMENTS AND

CONDITIONS CONTAINED ON THE BACK OF THIS FORM

X

SIGNATURE DATE

SIGNATURE OF PROVIDER OR PERSON AUTHORIZED BY PROVIDER TO BIND PROVIDER BY

ABOVE SIGNATURE TO STATEMENTS AND CONDITIONS CONTAINED ON THIS FORM


OPER ID ______________________________________

ACTION CODE ___________________________________

IMPORTANT


DATE BILLED

CITY STATE

ZIP CODE


Claim for Payment Attach a copy of form

Date of Service_______________________

Treatment Authorization Request (TAR) Attach a copy

of form

CLAIMTAR TRACER ONLY

CLAIM RE-EVALUATION ONLY

Please re-evaluate modificationdenial of claim

for payment I have attached all necessary

radiographs andor documentation


Anytown CA 95814

Last First

99999999999999

MM DD YY

X

Please research claim for DOS MM DD YY- we have no

record of payment Thank you


MM DD YY

Mary Jones MM DD YY

CLAIM INQUIRY FORM (CIF)

There are 2 uses for a CIF

1 CIF Tracer 2 Claim Reevaluation

CIF Tracer

1 Review instructions

2 Forms usually lsquopre-printedrsquo with your provider information

3 Fill out the lsquopatient informationrsquo

4 Tell us what you are requesting (do not leave this area blank)

5 Be sure to lsquosignrsquo form

image1png



POBOX 15609

SACRAMENTO CALIFORNIA 95852

Phone (800) 423-0507

PATIENT NAME

DOCUMENT CONTROL NO

PATIENT MEDI-CAL ID NO

PATIENT DENTAL RECORD NUMBER

DATE BILLED




YY30900132



Anytown CA 95814

Last First

99999999D MM DD YY


7AW MM DD YY

BY DATE

Upon your submission of a CIF Tracer DCal will lsquoresearchrsquo your request amp will send out a

CLAIM INQUIRY RESPONSE (CIR)

1 Computer generated form

2 lsquoCRNrsquo not lsquoDCNrsquo

3 Patient info Response info

4 Easier to call amp get the issue resolved over the phone

image1png

RESPONSES TO CIF INQUIRIES

The Claim Inquiry Response (CIR) (ClaimTAR Tracer)

After resolving your CIF Tracer inquiry The Medi-Cal Dental program will send youroffice a computer-generated CIR The CIR explains the status of your claim or TARIt contains the same information as the original document submitted by your officeand will identify the patientrsquos name Medi-Cal ID number dental record number (ifapplicable) DCN of the original document and the date services were billed Themiddle section of the form under the heading ldquoIn Response to your Medi-Cal DentalInquiryrdquo contains a status code and a printed explanation of the code

The Explanation of Benefits (EOB) (Claim Reevaluation)

After processing your CIF for claim reevaluation the response will be indicated onthe EOB under ldquoAdjustment Claimsrdquo

58


B-PRL-TRN-006AC


CLAIM INQUIRY FORM











XSIGNATURE DATE


FOR MEDI-CAL DENTAL USE ONLY

OPER ID ______________________________________

ACTION CODE ___________________________________

IMPORTANT


DATE BILLED

CITY STATE ZIP CODE


Claim for Payment Attach a copy of formDate of Service ____________________

Treatment Authorization Request (TAR) Attach a copy of form



DC 003 (R 0709)



Anytown CA 95814

Last First

99999999999999

YY283101357

X

Please re-evaluate 15 procedure D7210 - X-ray attached(or submit digitized image reference number)

Mary Jones mm dd yy

59B-PRL-TRN-006AC


CLAIM INQUIRY FORM



PO BOX 15609


Phone 800-423-0507
















X

SIGNATURE DATE




OPER ID ______________________________________

ACTION CODE ___________________________________

IMPORTANT


DATE BILLED

CITY STATE

ZIP CODE



Date of Service ____________________


of form






DC 003 (R 0709)



Anytown CA 95814

Last First

99999999999999

YY283101357

X

Please re-evaluate 15 procedure D7210 - X-ray attached

(or submit digitized image reference number)

Mary Jones mm dd yy

2nd use for CIF = Claim Reeval

1 You have 6 morsquos from your lsquoEOB datersquo to send CIF

2 Be sure to include the information exactly as it appears on your EOB - Patient name DCN amp Pat ID

3 Donrsquot forget to complete the lsquoRemarksrsquo section (tell us exactly what you would like DCal to do

4 Donrsquot forget to sign the CIF

image1png

Provider Appeals Process

First Level Appeals

60B-PRL-TRN-006AC

THE PROVIDER APPEALS PROCESSA provider may request a First Level Appeal by submitting a formal written grievance to theMedi-Cal Dental program Submission of a CIF is not required prior to the First Level AppealThe First Level Appeal procedure is as follows

1 The appeal must be submitted in writing to the Medi-Cal Dental program within 90 daysof the action precipitating the complaint or grievance Do not use a CIF for thispurpose

2 The letter must specifically indicate a request for a First Level Appeal3 The appeal must clearly identify the claim or TAR in question and describe the

disputed action4 Keep a copy of all documents related to the appeal5 the Medi-Cal Dental program will acknowledge the appeal request with in 21 calendar

days of receipt6 Direct first level appeals to

California Medi-Cal Dental ProgramAttn Provider First Level AppealsPO Box 13898Sacramento CA 95853-4898

The Medi-Cal Dental staff (including professional review if necessary) will review the appealand respond in writing if the denial is upheldJUDICIAL REMEDYA provider who is dissatisfied with the appeal decision may then use the judicial process toresolve the complaint In compliance with section 141045 of the Welfare and InstitutionsCode the provider must seek judicial remedy NO LATER THAN ONE YEAR after receivingnotice of the decision

61


B-PRL-TRN-006AC



CHECKNoPROVIDERNo





BIRTHDATE

ADJUSTMENT CLAIMS

CLAIMS SPECIFIC NON CLAIMS SPECIFICCHECK AMOUNT

1234567899 00596352


10100 8500 18600

CB



BENE ID

DOCUMENTCONTROL NO

TOOTHCODE

PROCCODE

DATEOF SERVICE

STA-TUS

REASONCODE

AMOUNTBILLED

ALLOWEDAMOUNT

SHAREOF COST

OTHERCOVERAGE

AMOUNTPAID


AMOUNT PAID ADJUSTMENT AMOUNT PAYABLES AMOUNT LEVY AMOUNT AR AMOUNT

C 30 NEW OR ADDITIONAL DOCUMENTATION SUBMITTED C YY168101357 15 D7210 1010YY A 266B - 9500 - 00 - 00C 14 D2140 1010YY A - 5000 - 3900 - 3900C 13 D2140 1010YY A - 5000 - 3900 - 3900

CLAIM TOTAL -19500 - 7800 - 7800


CLAIM TOTAL 19500 16300 16300



----------------------------------------------------------------------------------------------------------------------------------WHEN APPLICABLE ALL SERVICES SUBMITTED FOR MEMBERS UNDER 21 YEARS OF AGE

HAVE BEEN EVALUATED FOR EPSDT CRITERIA266B PAYMENT ANDOR PRIOR AUTHORIZATION DISALLOWED LACK OF RADIOGRAPHS

62B-PRL-TRN-006AC



CHECK

No

PROVIDER

No


of 3


P = PAID

D = DENIED

A= ADJUSTED

PLEASE CALL (800) 423-0507


BENEFICIARY NAME

MEDI-CAL

ID NO

SEX

BIRTH

DATE

ADJUSTMENT CLAIMS

CLAIMS SPECIFIC

NON CLAIMS SPECIFIC

CHECK AMOUNT

1234567899

00596352

Adams James DDS

30 Center Street

Anytown CA 95814

10100 8500 18600

C

B




BENE ID

DOCUMENT

CONTROL NO

TOOTH

CODE

PROC

CODE

DATE

OF SERVICE

STA-

TUS

REASON

CODE

AMOUNT

BILLED

ALLOWED

AMOUNT

SHARE

OF COST

OTHER

COVERAGE

AMOUNT

PAID


AMOUNT PAID

ADJUSTMENT AMOUNT

PAYABLES AMOUNT

LEVY AMOUNT

AR AMOUNT


C YY168101357 15 D7210 1010YY A 266B - 9500 - 00 - 00

C 14 D2140 1010YY A - 5000 - 3900 - 3900

C 13 D2140 1010YY A - 5000 - 3900 - 3900

CLAIM TOTAL -19500 - 7800 - 7800



C YY168101357 15 D7210 1010YY P 9500 8500 8500

C 14 D2140 1010YY P 5000 3900 3900

C 13 D2140 1010YY P 5000 3900 3900

CLAIM TOTAL 19500 16300 16300



----------------------------------------------------------------------------------------------------------------------------------


266B PAYMENT ANDOR PRIOR AUTHORIZATION DISALLOWED LACK OF RADIOGRAPHS

ADJUSTEMNT CLAIMS section of the EOB

1 When claims are reprocessed thru a CIF or an Appeal they will appear in this section

2 The patientdocument is listed twice

3 It is basically lsquobacked outrsquo of the system so that it can be reprocessed

In this example

- tooth 15 is disallowed then allowed amp $8500 is now being paid on this EOB

5 See the lsquoForms Sectionrsquo of your lsquoDCal Provider Handbook for complete instructions

image1png

Additional Services offered by

The Medi-Cal Dental Program

63B-PRL-TRN-006AC

B-PRL-TRN-006AC 64

Free Services Offered Toll Free Lmiddotnes for

Providers 1-800-4-23-0507 Members 1-800-322-6384

Interactive Voice Response System ( IVR)

Onsite Training Visits

Seminars

-

Case Management and Care Coordination Services

American Sign Language(ASL) and Language Services

Ill -----

For additional information and services see page 66-73 of the printed packet

- Ill -

American Sign Language Medi-Cal Dental reminds providers that American Sign Language (ASL) translation and language assistance services are available to Medi-Cal members at no cost

bull Provider or member can request language assistance by calling the Telephone Service Center (TSC)

bull Language assistance over the telephone or to schedule an ASL translator to be present at the time of the appointment

bull Providers can supply a language interpreter in the office or providers can call the TSC to access language interpreters available in 250 languages and dialec s

bull Free language tagline signs are available

httpssmilecal iforn iaorgpartners-and-providersprovider office language assistance sign

81

B-PRL-TRN-006AC 65

Language Assistance Services bull Provider requesting translator for member should call

Telephone Service Center at (800) 423-0507 bull Member requesting Translator should call

Telephone Service Center at 1-800-322-6384 bull Members with hearing or speaking limitations can call

Teletext Typewriter (TTY) line at (800) 735-2922

n

(Monday through Friday 8 am to 5 pm at all other times Medi-Cal members should call the California Relay Service TDDTTY at 711 to receive the help they need) Refer to bulletin volume 35 number 12 in the bulletin section of the Medi-Cal Dental website

82

TELEPHONE INQUIRIES

Provider

For inquiries or general information call the Medi-Cal Dental Program Customer ServiceTelephone Center toll-free at (800) 423-0507 When calling please be prepared with thefollowing information where applicable

1 Billing provider name and provider number 2 Memberrsquos name and ID number3 Type of treatment4 Document Control Number of claim or TAR6 Date of service and billed amount7 Check voucher number

The TSC representatives are available to answer questions from 800 am to 500 pmMonday through Friday (excluding holidays) The Medi-Cal Dental program encouragesthe use of the toll-free line for inquiries whenever possible Most inquiries can beanswered immediately by our telephone representatives However if the inquiry cannotbe answered immediately it will be routed to the telephone inquiry specialist and will beanswered by mail within 10 days of the receipt of the original telephone call

The Medi-Cal Dental program would like to give the best possible service and asks thatthe toll-free number be for provider assistance only Please do not give the provider toll-free number to the Medi-Cal Dental members

Medi-Cal Dental Members

The TSC toll-free line is available from 800 am to 500 pm Monday through Friday(excluding holidays) The toll-free number is (800) 322-6384

Members or their authorized representatives may use this toll-free numberRepresentatives must have the members name and ID number in order to receiveinformation from the California Medi-Cal Dental Program

Information about the program is available from the member toll-free telephoneoperators A few of the services are listed below

1 Referrals to Medi-Cal Dental dentists2 Complaints and grievances3 Assistance with scheduling or rescheduling Clinical screenings4 Information about Share of Cost and copayments5 Information about denied modified or deferred TARs

66


B-PRL-TRN-006AC

INTERACTIVE VOICE RESPONSE SYSTEM (IVR)

The Medi-Cal Dental IVR is an automated inquiry system for use by providersUsing a touch-tone telephone providers can communicate directly with anautomated voice response system Providers can access the IVR System bydialing the toll-free information line (800) 423-0507 from a touch tone telephoneThe IVR is available 24 hours a day 7 days a week for information that can beaccessed without a provider number The menu options that do not requireentering a provider number include

bull Billing criteria for procedures most frequently inquired about by providers

bull Upcoming schedule of provider seminars for the callerrsquos area

bull A monthly news flash consisting of items of interest to providers

bull Information about ordering Medi-Cal Dental forms

bull Information about enrollment in the Medi-Cal Dental Program

bull Transfer to a telephone representative for further inquiry

The hours for accessing information requiring a provider number are Mondaythrough Sunday from 200 am to 1200 midnight The optimum time to call isbetween 600 am and 1000 am or between 330 pm and 500 pm when callsare at there lowest level The menu options that do require entering a providernumber include

bull Patient history relative to specific service limited procedures

bull Status of outstanding claims andor TARs that the caller has submitted

bull Provider financial information (next check amount and net earnings for thecurrent or previous year)


67B-PRL-TRN-006AC

MEDICAREMEDI-CAL CROSSOVER CLAIMS

Medicare will pay for certain dental services See the MedicareMedi-CalCrossover Procedure Codes and Descriptions list in the Medi-Cal DentalProvider Handbook for procedures that qualify Medi-Cal Dental processesclaims and TARs for Medicare covered dental services in accordance with thefollowing MedicareMedi-Cal crossover policies and procedures

1 If a provider is not a Medicare provider indicate this in the comments section Box 34 on the claim form Submit the claim directly to the Medi-Cal Dental for reimbursement

2 A provider must be enrolled with the Medicare program to be reimbursed by Medicare

3 An enrolled Medicare provider may submit claims to the Medi-Cal Dental program for crossover procedures upon completion and approval of the MC 0804 Form The provider must currently be enrolled in Medicare must not be enrolled in the Medi-Cal Dental program and must be providing services to dual eligible members Existing Medi-Cal Dental providers do not need to complete this form The MC 0804 Form may be obtained from the Medi-Cal Dental website or by calling the Toll-Free Provider line

4 Approved and paid Medicare dental services do not require prior authorization from the Medi-Cal Dental program

5 Payment for a Medicare covered dental service does not depend on place of service hospitalization or non-hospitalization of a patient and has no direct bearing on the coverage or exclusion of any given procedure

68


B-PRL-TRN-006AC

HOSPITAL CASES

When dental services are provided in an acute care general hospital or asurgicenter document the need for hospitalization (eg developmentally disabledphysical limitations age etc)

To request authorization to perform dental-related hospital services providers needto submit a TAR with radiographsphotos and supporting documentation to theMedi-Cal Dental program Prior authorization is required only for the followingservices in a hospital setting laboratory processed crownsbridges prostheticsand implants It is not necessary to request prior authorization for services thatdo not ordinarily require authorization from the Medi-Cal Dental program even ifthey are provided in an outpatient hospital setting In all cases an operating roomreport or hospital discharge summary must be submitted with your claim forpayment

Services that require prior authorization may be performed on an emergency basishowever the reason for the emergency services must be documented Enclose acopy of the operating room report and indicate the amount of time spent in theoperating room

Hospital Inpatient Dental Services (Overnight or Longer)

If a provider is required to perform services within a hospital setting the provision ofthe medical support services will depend on how the Medi-Cal member receivestheir medical benefits Members may receive medical benefits through severaldifferent entities

bull Medi-Cal Fee-For-Service (FFS)bull Geographic Managed Care (GMC)bull Medi-Cal Managed Carebull County Organized Health Systems (COHS)

Refer to your Medi-Cal Dental Provider Handbook under ldquoSection 4 TreatingMembersrdquo to determine the entity providing a member medical services

Requesting Hospital Dental Services for Medi-Cal Members Enrolled in the Medi-Cal (FFS) Program

Authorization is required from Medi-Cal to admit the patient into the hospital

69


B-PRL-TRN-006AC

This authorization must be submitted on the Medi-Cal Form 50-1 which should besent directly to

Department of Health Care ServicesSan Francisco Medi-Cal Field OfficePO Box 3704San Francisco CA 94119(415) 904-9600

The Medi-Cal Form 50-1 should not be submitted to the Medi-Cal Dental programthis will only delay the authorization for hospital admission

If your patient requires emergency hospitalization a lsquoverbalrsquo authorization is notavailable through the Medi-Cal field office If the patient is admitted as anemergency case the provider may indicate in the Verbal Authorization Box on theMedi-Cal Form 50-1 ldquoConsultant Not Availablerdquo (CNA) An alternative is to admitthe patient as an emergency case and submit the 50-1 retroactively within tenworking days to the Medi-Cal field office

Your claim for payment of dental services is submitted to the Medi-Cal Dentalprogram and must be accompanied by a statement documenting the need andreason the emergency service was performed Include a copy of the operatingroom report

Requesting Hospital Dental Services for Medi-Cal Members Enrolled in the GMCCOHS or Medi-Cal Managed Care Plans

The dentist must contact the patientrsquos medical plan to arrange for hospital orsurgicenter admission and medical support services All medical plans that provideservices to Medi-Cal managed care members are contractually obligated to providemedical support services for dental treatment If the Medi-Cal Field Office receivesa Form 50-1 for a Medi-Cal patient who receives their medical benefits through oneof these programs the form will be returned to the submitting dentist

MAXILLOFACIAL-ORTHODONTIC SERVICES (MF-O)

All MF-O surgical and prosthetic services TMJ dysfunction services and servicesinvolving cleft palatecleft lip require prior authorization The exceptions to this arediagnostic services and those services performed on an emergency basisProviders and their staff should be aware of the procedure codes specific to theMF-O program These codes are listed in your Medi-Cal Dental ProviderHandbook

70


B-PRL-TRN-006AC


ORTHODONTIC SERVICES

Orthodontic benefits for eligible individuals under the age of 21 are available under theCalifornia Medi-Cal Dental Program when medically necessary Services must beperformed by a qualified orthodontist who is enrolled as a Medi-Cal Dental providerThis program covers handicapping malocclusion cleft palatelip and cranio-facialanomalies cases A Handicapping Labio-Lingual Deviation (HLD) Index CaliforniaModification Score Sheet must be submitted to document the medical necessity Todocument a handicapping malocclusion it is necessary to have a minimum score of 26on the HLD score sheet There are also six automatic qualifying conditions cleftpalate deformity cranio-facial anomaly a deep impinging overbite causing destructionof the palatal soft tissue an anterior cross-bite causing clinical attachment loss andrecession of the gingival margin severe traumatic deviation or an overjet greater than9mm or a mandibular protrusion greater than 35mm See Provider Handbook page9-11 for more information

CALIFORNIA CHILDRENS SERVICES (CCS)

The CCS program provides healthcare to children and adolescents under 21 years ofage who have a CCS-eligible medical condition Patients must apply to CCS to beeligible for services provided under this program The patientrsquos caseworker can referthe patient to his or her local CCS county or regional office

All CCS dentalorthodontic providers must be enrolled and active in the Medi-CalDental program prior to receiving payment If a provider has a valid authorizationissued by the CCS program the authorization will be honored through the expirationdate Continue using the same processing guidelines that were in place when theservices were authorized

Program Guidelines

All CCS members are subject to the scope of benefits prior authorization andprocessing guidelines as defined in the Medi-Cal Dental Provider Handbook The CCSProgram only authorizes dental services if such oral conditions affect the memberrsquosCCS-eligible condition See Provider Handbook page 9-1 Special Programs formore information

CCSMedi-Cal The CCS program will no longer issue authorizations for CCSMedi-Cal members Providers are to submit all claims and TARs directly to the Medi-CalDental program If a member requires services beyond the scope of the Medi-CalDental program they may qualify for the Early and Periodic Screening Diagnosis andTreatment (EPSDT) program

71B-PRL-TRN-006AC

CCS Only CCS eligible members will continue to require service authorizationrequests (SARs) from CCS Providers must request a SAR from the CCS countyor regional office prior to submitting claims and TARs to the Medi-Cal Dentalprogram

THE PROFESSIONAL COMPONENT

The Medi-Cal Dental program has a professional unit consisting of dentalconsultants who are licensed dentists The consultants review all claims and TARswhich require professional judgment These dental consultants assist the Medi-CalDental Program ProviderMember Services and Clinical Screening departmentswith reevaluations and special cases

In addition there are clinical screening dentists located throughout the state Theyare responsible for pre-screening cases that may require clinical evaluation underthe guidelines of the Medi-Cal Dental program

After the clinical screening dentist has examined the patient the screening report isreviewed by a Medi-Cal dental consultant The claim or TAR is subsequentlyapproved modified or denied The Medi-Cal Dental clinical screening dentists alsodo post-operative screenings

ONSITE TRAINING VISITProvider Representatives are available for On-site visits to assist providers withpolicy or billing issues that cannot be resolved by telephone or writtencorrespondence Medi-Cal Dental will determine the necessity to schedule an on-site training visit To request a visit please contact the Telephone Service Center at(800) 423-0507

SEMINARSThere are four types of Medi-Cal Dental Seminars- BasicEDI AdvancedWorkshops and Orthodontic All seminars are free of charge and offer continuingeducation credits based on the hours of training conducted Visit the Medi-CalDental website at wwwdentaldhcscagov or you may contact the telephoneservice center for the current seminar schedule and to make a reservation

72


B-PRL-TRN-006AC


American Sign Language (ASL) translation and language assistance services are available toMedi-Cal members at no cost Either the Medi-Cal dental provider office or the member can callthe Telephone Service Center (TSC) Monday through Friday between 8 am and 5 pm torequest language assistance over the telephone or to schedule an ASL translator to be present atthe time of the appointment Providers can supply a language interpreter in the office orproviders can call the TSC to access language interpreters available in 250 languages anddialects

Medi-Cal dental providers should call the Provider Telephone Service Center at (800) 423-0507and Medi-Cal members should call the Medi-Cal Dental Telephone Service Center at 1-800-322-6384 Members with hearing or speaking limitations can call the Teletext Typewriter (TTY) line at(800) 735-2922 Monday through Friday 8 am to 5 pm At all other times Medi-Cal membersshould call the California Relay Service TDDTTY at 711 to receive the help they need

CASE MANAGEMENTDental Case Management is designed to assist Medi-Cal members with special health careneeds who are unable to schedule and coordinate complex treatment plans among multiplepractitioners This is a program designed for members with mental physical andor behavioraldiagnosis or diagnoses who are unable to schedule and coordinate complex treatment plansinvolving one or more medical and dental providers

Some examples of qualifying special healthcare needs include physical developmental mentalsensory behavioral cognitive or emotional impairment or other limiting condition that requiresmedical management health care intervention andor use of specialized services or programsReferrals for Case Management services are initiated by the membersrsquo Medi-Cal dental providermedical provider case manager or case worker and are based on a current comprehensiveevaluation and treatment plan

The Case Management referral form is located on the Medi-Cal Dental websitewwwdentaldhcscagov Members must be referred by a Medical or Dental professional bycompleting the secure online referral form After completing the referral form it must be emailedto DentalCaseManagementdeltaorg Please visit our Provider Forms PageDental CaseManagement section to download and submit a Case Management Referral form If you havequestions when submitting an online referral please contact the Telephone Service Center at(800) 423-0507

CARE COORDINATION SERVICESCare Coordination services are offered by the Telephone Service Center (TSC) CareCoordination Services allow Medi-Cal members to call and gain access to dental services with thedirection and support of our TSC representatives who assist members with Locating a Generalor Specialist Dentist Accessing Appointments Translation Services Transportation AssistanceMembers can access the Care Coordination Services by contacting the Telephone Service Centerat (800) 423-0507 and request Care Coordination assistance

73


B-PRL-TRN-006AC

Medi-Cal DentalEDI

ElectronicDataInterchange

74B-PRL-TRN-006AC

75B-PRL-TRN-006AC

Did You Know

bull Medi-Cal Dental has been accepting ED I documents since 1994

bull EDI claims are processed an average of five days faster than paper claims

bull Over 70 of Medi-Cals Dental incoming documents are received electronically

Why EDI

bull To maximize computer capabilities

bull To make billing simpler

bull To have fewer rejections

bull To have tracking capabilities

bull To receive payment faster

bull Saves Money - Estimate your savings on the NDEDIC website

76B-PRL-TRN-006AC

1 From the website wwwndedicorg

2 CI ick on the Resources Tab and select the EDI Savings Calculator

3 Enter your data

4 Click Calculate to see your savings

See What EDI Can Do For You ~iJdlllDllilllaquoM~bull-m-njlmMliM-U~ lialliin1raquo8~~-tt lfNHOl l lllellffli _-lOilgJbulliinilldfisdwt-1 pound00JIIOl1-0EDCbulllaquol~t-- ~~

~-shy--- -middot -____ ___

_-middotfl--middot bullNbull- bull - -bull-- bull-

f

f -

--middot -- bulli-__ -middotmiddot-

lOI wti LllnnLUl cbtu _Ur-1 r-=ii--=-Yrii Da-llaquo11 ~ -1 ~trrcit~fl 11JJOC tJ~ UtlU l tQ ~ ti Q1poundll -nf3 9q nlJ UD t4I NIN~_ lo_~ q_

bullbull-ir-otVri ______r-1bull--- p-11111111---___ __ c ____ _ _ -Ml-liift wDfn~_ nCOI

Getting Started With EDI bull Must have practice management software or access to the Internet

bull If necessary enroll with the clearinghouse that works with the offices practice management software

bull Must enroll with the Medi-Cal Dental EDI Department

bull Do not send electronically until the office has been notified of activation by the Medi-Cal Dental program

bull Take a few minutes to read the EDI How-to Guide

B-PRL-TRN-006AC 77

When Preparing An EDI

Document Comple e required fields

Check for atturate lnformaton

Use the ~omment or note section ol the software to proade addltonal written lnfonnallon

Use only the current CDT procedure code forrna

Cllearinghouse Dai y Reports

bull Submitter Report -

This report is generated prior to the transmission of the claims to the clearinghouse

bull Transmission Summary Report -

This is verification that the claims have been received by the clearinghouse and have been submitted to the appropriate payers

78B-PRL-TRN-006AC

Medi-Cal Dental Program EDI

REPORTS

bull bull

~-----------------------~-------66 _______________________ ~ B-PF1-JRN-IJ05AB

Daily EDII Documents Received Today

CP-0-973-P

REPORT ID CP-0-973-P MIDI-CAL DENTAL

PERIOD EtfDING MMDDYY PROVIDERSVC OEC

PROORAM ID DCB97las DJlILY EDI OOCOMENT9 RECErVED TOOAY

PROV51C PROVIDER

OR NPI DCN

a oa oa oa oa o aa oa oo oo o bull middot MEDI CAL gtlBR aoooooooooooao

a oa oa oa oa o aa oa oa oa o MIDI CAL NBR 00000000000000

0 00 00 00 00 0 00 00 00 00 0

BASE RECIPIENT N1IME

DCN LAST EIRST

noooaooooo LAST EIRST

DOC T lPE C SUBMITTED FEE

oaoaoaooa ~ -rRsT DOC TYPE a SUBMITTED FEE

YYOOOOOOOOO LAST EIRST

MIDI CAL NBR 00000000000000 DOC TYPE C SUBMITTED FEE

aoaoaoaoao aaoaoaoao ~yooooooooo LAST -rRsT MEDI CAt NBR 00000000000000 DOC TlPE C SUBMJTTED FEE

aoaoaoaoao aaoaoaoao TYOaoaooaoa LAST -rRsT MIDI CAL NBR 00000000000000

0 00 00 00 00 0 00 00 00 00 0

MIDI CAL NBR

DOC TYPE T SUBMITTED FEE


DOC TYPE C SUBMITTED FEE

0000000000 aoooooooo HOOOOOOOOO LAST EIRST MEDI CAL NBR 00000000000000 DOC TlPE C SUBMITTBD FEE

aoaoaoaoao aooaoaooo TYOaoaooooa LAST -rRsT MIDI CAL NBR 00000000000000 DOC TYPE T SUBMITTED FEE

0000000000 000000000 YYOOOOOOOOO LAST EIRST

MIDI CAL NBR 00000000000000 DOC TYPE T SUBMITTED FEE

TOTAL PROV SVC CFC DOCUMEJJTS

9 -

RUN ON DDn

PAGE

55NCIN

OR MIDS

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331 00

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oaoaoaoao 30 00

oaoaoaoao 100 00

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79B-PRL-TRN-006AC

ProviderService _ ~----- -------------------EIIN- Olf_ _~-----DD----lY---- Office Document =~ItltG ~-e ffiltJV=~~rAL PAGB l

_ 1

_ - 0

- - - - - - - eT rn OC896965 bullbull llCCtradeElTr IONS bull Re1ect1ons Report eaovs~ eROHDUI =m= NllMrO D SSNCIN RSII

j CR NeI OCN IAST FIRST T OR EDS ASE OCN CD

CP-0-959-P 0000000000 0000000000 0000000000

000000000 000000000 000000000

PROVrDERISERVICE OEC TOTALS

LAST LAST

LAST

A bull lWlll11) ~INC OliC B - lNVALXD CH

C - INVALID eROV Cll D - EYlTCH REJECTED

E - EgtfCORD COUNlS HJSHMCtt ~ F - INVALID EROVIBR NJIME

I ~ Ii - WHtiAlE tlOC1MEWlS H - SEOCill~ NOA I SSllED

I - INVALID REIVRN OCN J - SUBPRO SITE MISMMCH

- CU OVR 90 LINES - 4010 L - tlSE CIM OR BIC-NOT SSN

M - FILE VERSictf NOT AJJrEI N - bullFCCN REQlJIRED

P - CU OVR 50 LINES - 5010

TOTAL REJECTICfiS

FIRST EIR9T

FIRST

The Binder System

C C

C

- --------- -- A ---

A

G

bull One way to manage the EDI reports is The Binder System

- ~ --

bull In a standard three ring binder bull Place index tabs numbered 1-31 (for the days of the month) bull Fille the Transmission or CP-0-973-P report under the date billed from

the office

bull This gives a starting point to track the EDI claims

B-PRL-TRN-006AC 80

The Binder System lltH0H I D Clbull0-91SbullI lGDlbullCM DlfNlY WN ON IOIDDIt PDlltCgt ~Illlt 1911raquoYY ncent1111) = OPe PMZ 1 ~ II) 1HJ~S~ DAlLY IZgtI El0oklm$ UalVZZgt =tY

bullntfl$V ntID - Utl - ~CIII bull OJ lltl Dell Dell -MT PIMT OJ HIZgt$ diams ---------- ----------------- ----------- ------------ ---------- --------- oooooooQcO D McDlU YYXlOCXlOOOCX==middot middot = middot -bull=us-T - ---------tlo-uo-00-000-- alMDDJYY ~ MmI CAL NlR o 000 00 o-ao-oo 0-00 DOC TYEE C SUBMIT-lm FEE 11 10-1) oooooooQcOO yQcOOOOOOOQcOOOOOOO alMDDYY bull MlllgtI CAL 1R 0 OQcO 00 0 0000 0 00 OOC TYE C pound 1WUTTEll FEE OOOOOOOQcOO yQcOOOOOOOQcOOOOOOO YYXlOCXlOOOCX FiltST ~ MmI CAL ~ 0 IHlO 00 0 ao 00 0-00 IX)C TYEE c SUBMIT-rm FEE OOOOOOOQcOO YmiddotOOOOOOOOQcOOOOQcOO YYXlOCXlOOOCX FiltST ~ MmI CAL ~ 0 IHlO 00 0 ao 00 0-00 ilXgtC TYEE T SUlMIT-rEil) FEE

bull lOl1tL ncent11= OFO ~$ 4

~O ltO middotOOOOQcOOOO

2U 00 OOOQcOOOOO

1100

_

bull Indicate the date each claim is processed on the CP-O-973-P report

bull Remove page once an claims are processed

bull This quickly identifies the claims that have not been processed at the end of each month

Claims with Attachments

bull Using the Base DCN listed on the report id CP-O-971-P mail radiographs to the Medi-Cal Dental program using special EDI labels and red bordered envelopes

or

bull If the office is enroUed with a digitized imaging company follow the format and instructions provided on sending digitized images of radiographs photos Justification of Need (DC-054) forms and narrative reports to the Medi-Cal Dental program

81B-PRL-TRN-006AC

Digitized Images

bull The digitized i1mage number must be the 1st item in the commentsnotes field

bull Dont forget to middotnclude the sign

(N EA999999DTX9999999EH G9999999CHC9999999)

bull The date on the radiographs should match the mage created date (or the date the filmsensor was actually in the patients mouth)

Digitized Images

bull Offices using a digitized imaging company to submit radiographs and attachments should still be familiar with the label process

bull If radiographs or attachments are not successfully submitted using digitized imaging the office willl receive the CP-0 -971 -P report

bull It will then be necessary to submit radiographs and attachments using the label process

82B-PRL-TRN-006AC

EDI Labels

Labels must middotnclude

1 Billing NPI

2 Members first and last name below PATIENT MEDS ID

3 Base DCN

4 Providers name and address

u y

0

Claims With Attachments

CP-0-971-P

lllll N l I mxxxxxxx PT TW Dall

PHCvDC P JASt ~ tASl

----middot Clft ~ CA 00000

IElORT ID CP-O- ~71-P HllDI-CAL DllWAL JI bull ON ~DDIYY PJRIOD llVDI PJIOGllM ID

~I DDYY PROVIDEJli SVC OfC PAGE 1 DCl~71BS X-AAYATTACIIMllliI JILQliLST

PROVSVC MSE OJI NP OOJil

0000000000 nooooooooo HllDI CAL bull 000000000

0000000000 YOOOOOOOOO 000000000 YYOOOOOOOOO

J1BDI C1L R 000000000 0000000 0 YYOOOOOOOOO

PROV OOJil

11ECIPlW LAST

N~MB FIJSI

00000000000000000 LAST rIJSI SYS IND DOC TYPE C lllmIT ~MOlgtST

00000000000000000 LASV lIRSV SYS IND bull bull bull DOC VYPB V SOBJill MOIJNV

00000000000000000 LAS FIRSV SYS IND bull DOC VYPB C SIJBlIV MOIJNV

00000000000000000 LAS FIRSV

llllliCINI OJIHllDll

JO 00

20000

H30 00

SYS IND bull DOC VYPB C SIJBlI MOIJNV 100 00

FJOlllJiQ UIJ111 u La 11111

tMaTO

Finl (IMS 1111111

m1FbullncPMt-nJ _Q 80--11113SJ

GI _

83B-PRL-TRN-006AC

EDI Documents Waiting Return

CP-O 978-P

~

PERIOO ezmr~ JfiDOn PJIOVIDBRSVC OiC

PgtJN 00 wcllPIYC

PAGEi

o~SJ 8~ CAII~ CIII oocaum5 llllUUii ir7LTJUi U lCiJIIAlICN i J DAr s

=bull B~CUU NEDI-CAL RCIPIENt

oooc000000 -iotn 40 000000000

PRO DCN1 OQOOOQOOO(XI BA8 OCNI rYIJOl(IIJOIJ(II) OOC lCPB1 C BIJI A)f] r

OOOOOOOC-00 ~ ton 24 0 000pound11)00pound11000pound11) JJ

PRC OCN I 00000000000 l BIJB AH I

0000000000 000000000 00000000000000 ~

l (lIJI A)f] 1

000000000 000110001)00011) l1

fYOOOOOOOOO OOC lPB I C BIJB AH t

lJPlt AlGJtJ DOC ~

11)310 ~ ~L--------------1 lIP11 JODIl Do bull-u~~bulln~~ ~

H8E-DQ

ltPlr x~clAlrcit

1001)0 ~ middot3 llaquoJ -- -middot middot------middot ------ nn_ _ -----_ n_ _ __ __ lllUll ~

Ulla nPD - --

11111 _n__l_J __

_TITIVTI ___ _nu _-rtbullbullll bull11 nttbullbull bull-n_ bull ~tnir-11 INII wn1r 11 ta ar~ - 1--~I TITWTI-lffnlWJ_bullll]lllIII Wf _ __ -- 11 lINTlI

sirt1ile CALIFORNIA Mlbi-CAL HAS D~HTAL~D

84B-PRL-TRN-006AC

CP 0-RTD-P Notice of Resubmission

RTD fCP-0RMgt-PI a NOIICI or Ni1maSHON BOSINESS WJ4B AND ADDRESS

0001Y1 20~319 ria 01 or 01 HD HSVI ~fl HKDDn

SBRltICB OTICB ncnuoDS WJ4B 1[JM JAHBS rutO INC

123~561891 HD DUI DOCH )G1DDYI _ _

30 CENTER SVREBV DOCUKENV VYPB lJt ---BEGINNING DOS

ANVOliN CJ 90250-3801 ------------PArIBNV INfQRhUON

PROJlDBR OCN 000000000000000

INiFORHAlION BLOCK V00gt8-COOB

rIRSV WJ4B MEDICAL ID NBR DENVAL REC HJ_t 00000000000000

CLAill

MOON BILLED 100 00

nBLD CLAIM SDBKinBD PROCBDORB ND LINE INFORhUON CODE 26 01 10 D2191

OCN nooooooooo 1

ERROR CD 32 DBSC SOflIU CIJRRSNV K-RAY rs I SBO~ING APICBS Oi roora CORRBCV INFORhHON

VOOlB-COOB 26 01 10 D2191 BRROR CD 31 DBSC SOBKIV CIJRRSN K-RAYSIPBOOORAPBS CORRBCV INfORhrION

--- K _______ _ SIGNAVORB DArB

NOVB PLEASE CORRBC VBB CLAIIIIVARNOA RBSOBKIV A COPY Of VBIS FOR VBRO VBB 111lL MIL ANY RBQOIRBD K-RAYSAVACBENS IN VBE APPROPRIAVELY COLORED ENVELOPE ~RIUNG IN VBB DOCUKENV CONVRDL NOMBBR fOCNI PLEASE INCLODB ras EDI-CAL DBNVAL ASSIGNED OCN ON ANY OlBBR CO_HIONICAlIONS ~IVB EDI-CAL DENVAL

(CP-C-lfCA~ lllO[]CI or AIJIHCfllZAIIltN ttlDD11i Olri316~ Pim 0 ) or 01 ~ DCN I n000000000 1 Len3li UiIIClf fEFICO ~ tlIDDYY IC tOVCOTI ~ - ---f---

ft-EJLOlfl~ IS RECIJSIEC _ 11 CG 1~ 1

------fAIIEtrI IWII(LASirFIJattUI Ua31 FIilst

SEI BlJ121lUE HECgtI-GM-ID lllO r----shy llllXX 000000~

CP 0-NOA-P Notmiddotce of Authorization

fllIEHI DpoundHrlJ ~ 9) I

fRCVICpoundR DOO otl1[JOL tQfBER1 ioABziti Ol(tfJoo-Q

X-RAYS AIIACHED II FCG lUII HC1 JGlfY ICC]Ifl I INJURY II FCG JEI) ltgtIKER AIIACHHEKii II poundOJ ua) - IEltPICrn[Kl 8EUiIED - 11 ~ 1D) -0-IHER ClHll c~ _ II reR ~a raDE 11 FCG rd)

12H6618~1 BIJUNESS twfE AlfD IDDilS5I MW JJampKES DOS IPC ll]C ISSIJE GAIE1 ____ _

lO C-EHUR SiflEEI EioC _______ _

AITIClfN GI SQZS0-~1

I-0 SUBf CH Cpound8CBH1le5-0f-SwC DiUE-fE9 on poundltire fEE Al-tClf IIIJgt-C ei071[) 18 01 fFEfA3illCJtiED Kt9I ___ 0 DZ9-S1 0000 l-2S 18 oa flJLt aLST tretll aOiil --- Ol D21511 iQ000 H6iioI

--------------- GAIE fflCSIHESIS ltmallD I ---- 11 lCtJJ rd OWlGE[) fMSIHESIS LIKE Irdt I F01JL ILLOiAHCE ------------ -_-_-_ _ EJtm S31BE-Cf-CCSI Jtlt

OlEB CUll6E AMI CCfrac14OEtrIS I mw EllLLD fMHEHI 9ECUESI lD5T 81 limpound9IHG FilCV lD bull PLEASE HOIE I ti31S lEl03 ltll CHLt BE ELIGl3LE IJNCpound8 A FHP HCP Etpound EtKl Oi DKC tfHICH ~ Dl1tM fLEllSE VEflIFi ECD3lBlllY NJ~ fliJ SD]C55

middotmiddot--~~~(JU= =---

laquo100 1 086

HCIE I f[EllSE REfD [(I Tii118 Efl (1 ~000000~ a1i1 llL CUB CCD[IJNJ0t](tll5 vrra

HE[)I-CAL c-anrr l~HG ELEClflCffIC ~ilCHS CCHCEFlHIPJ Ti3lS DOIJUHEtrI

NOA

85B-PRL-TRN-006AC

EDI Document Control Numbers

bull How to identify EDI claims on an EOB

bull All EDI Document Control Numbers (Base DCN) have a 6 8 or 9 as the 7th digit

Example YY0091 8XXXX ___ __

------=-~ __ middot3 i middot-- - _

ff~- ~- - - _ - _

~

EDI Support

Please contact the EDI department for additional information

EDI Support may be reached by phone or email at

(916) 853-7373

medi-caldenta led ideltaorg

10 5

GLOSSARYBILLING PROVIDER The dentist who bills or requests authorization for services on the treatment form

TREATMENT AUTHORIZATION REQUEST (TAR)CLAIM The State approved universal form used by the provider to request prior authorization of services andor the form submitted by the provider to request payment for services performed

CLAIM INQUIRY FORM (CIF) The form used by the provider for tracing a claim or TARor for requesting a reevaluation or adjustment to a previously submitted claim

CORRESPONDENCE REFERENCE NUMBER (CRN) An identifying number assigned toall telephone correspondence written correspondence and CIFrsquos received by the Medi CalDental program

MEDI-CAL DENTAL The Fee-for-Service portion of the California Medi-Cal DentalProgram

MEDI-CAL DENTAL BULLETIN A publication with information regarding programupdates pertinent legislative action procedure clarifications and other important itemswhich affect the California Medi-Cal Dental Program The bulletins may be accessed fromthe Medi-Cal Dental website

MEDI-CAL DENTAL PROVIDER HANDBOOK A reference guide for all providers enrolledin the California Medi-Cal Dental Program It contains the criteria for dental servicesprogram benefits exclusions limitations and instructions for completing forms used in theMedi-Cal Dental program The Handbook may be accessed from the Medi-Cal Dentalwebsite

DOCUMENT CONTROL NUMBER (DCN) An identifying number assigned to all billingdocuments received by the Medi Cal Dental program The DCN enables the Medi-CalDental to track the document throughout the automated processing system

NOTICE OF AUTHORIZATION (NOA) A computer-generated form sent to the providerfollowing final processing of a TAR by the Medi-Cal Dental program When the NOA isreturned to the Medi-Cal Dental by the provider it becomes a claim submitted for paymentof services rendered

PROVIDER Individual dentists dental group dental school or dental clinic

RESUBMISSION TURNAROUND DOCUMENT (RTD) A computer-generated form whichthe Medi-Cal Dental program sends to the provider to request missing or additionalinformation needed to complete processing of a claim TAR or NOA

RENDERING PROVIDER The dentist who provides services that are billed under thebilling providerrsquos name and billing provider number The rendering provider may be thesame as or different from the billing provider

86


B-PRL-TRN-006AC


Slide Number 2

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Slide Number 35


Provider Forms

Slide Number 38



Slide Number 41

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Slide Number 46




Slide Number 50


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Slide Number 54

Provider Inquiries

Slide Number 56

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Slide Number 62

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Medi-Cal DentalEDI

Slide Number 75

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Slide Number 86

2B-PRL-TRN-006AC






Sincerely


3B-PRL-TRN-006AC





Introduction



Program Overview


4B-PRL-TRN-006AC

Program Overview



5B-PRL-TRN-006AC




Whats New

Important Reminders










S-lfOliceDeramp



~~2M1J




6B-PRL-TRN-006AC




n_r---



Log In middot usmam

middot Pass-




Manage User

middot-- _ -- _ --I


1~~ ~ 1


7B-PRL-TRN-006AC


Rendering Providers


8B-PRL-TRN-006AC







(CMS) Final Rule






9B-PRL-TRN-006AC




ma




~










10B-PRL-TRN-006AC











11B-PRL-TRN-006AC

12B-PRL-TRN-006AC

Eligibility










13B-PRL-TRN-006AC

14B-PRL-TRN-006AC







State of California



M mm dd yyyy








15B-PRL-TRN-006AC

16B-PRL-TRN-006AC

Eligibility










11-0 ~i-n

B-PRL-TRN-006AC 17


Med I-Cal Providers




IJHQyenKHJlJc

fifJ

Roi ~

Tfllll)ltfHYli



fiutgtIICltJllolgtS




~10ltJ-Clnbullw





18B-PRL-TRN-006AC

6 ligibility





OJ l llli

~ppeal Slaus mqolfJ


Prtntidcr Servitts





Swip Card

1pe Card

mmddY)YI




C~ SlllW~ lnq_uir_y






Single Subscriber

bull Subii riber lD

[ Subscnber ID

bull l uoDirto

mmGd fIYI mmddlvm


B-PRL-TRN-006AC 19






snti1 Dffl Olll2021

FimSPldlllldCampdai

HIC um1tr



Primary Aid Codit



~ (cnK1US

20B-PRL-TRN-006AC





receiving


-




-bull-1~__ ~---i-ot _ ______ i __ _ ___ -ai



-bull-









-middot lUHUl

1ll-1f2 i





21B-PRL-TRN-006AC

Aid Codes



22B-PRL-TRN-006AC

bull bull

bull

bull

bull







~Data MMDDIYYYY 00



ff lC-


OOOOOAKEOR








MMIDDIYYYY 00

secondary carrier



IC_


23B-PRL-TRN-006AC


or family


bull Updating SOC

bull Case Numbers








24B-PRL-TRN-006AC








25B-PRL-TRN-006AC



Benefits Emergency

Full Scope aid code

Child (under 21)



DDS Member









26B-PRL-TRN-006AC

Pregnant Members





27B-PRL-TRN-006AC


Overview of CalAIM




B-PRL-TRN-006AC 28


--











B-PRL-TRN-006AC 29


PROCEDURE CODE




MEMBERS OVER 21



$1800 $1350 X


$800 $600 X


1800 $1350 X


$800 $600 X



$2200 $1650 X


$12000 $9000 X


$20000 $15000 X


$20000 $15000 X


$23000 $17250 X


$23000 $17250 X


$3000 $2250 X


$3000 $2250 X


$3000 $2250 X


$3000 $2250 X


$3000 $2250 X


$3000 $2250 X


$12000 $9000 X


$1000 $750 X


$4600 $3450 X

B-PRL-TRN-006AC 30





B-PRL-TRN-006AC 31





D1310



Low risk

Moderate risk

High Risk


($1500) ($4600)

D0601 D1310 6 months $6100

D0602 D1310 4 months $6100

D0603 D1310 3 months $6100

B-PRL-TRN-006AC 32





bull A benefit


Photograph required




B-PRL-TRN-006AC 33








D0120D0145D0150 X X

B-PRL-TRN-006AC 34













dentaldhcsca gov

B-PRL-TRN-006AC 35

0






Senate Bill 639






36B-PRL-TRN-006AC


6 PATIENT ADDRESS

9


SERVICES

1

3

4

5

6

7

8

9

10

2



SIGNATURE DATE


X



DC-217 (R0909)






CHECK IF YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES



HOW M ANY_____________

11 CHECK IF

ACCIDENTINJURY

EM PLOYMENT RELATED









SERVICES





CITY STATE ZIP CODE


BIC Issue Date ________________

EVC _______________________


27 SURFACES



30 Q UANTI TY

31 PROCEDURE

NUMBER

32 FEE

33 RENDERING

PROVIDER NO


CHARG ED


AM O UNT


AM O UNT

38 DATE BI LLED

wwwdenti -ca lcagov






39

X


34 COMMENTS




HOW M ANY _________


41DELETE


3 SEXM F


23

16 CHDP


EMPLOYMENT RELATED

27SUR-FACES

28TOOTHNO OR

LETTERARCH

43 ADJREASONCODE

42ALLOWANCE

32FEE


31 PROCEDURENUM BER

30QTY

29 DATESERVICE

PERFORMED


35 TOTAL FEECHARGED

46 TOTALALLOWANCE


AMOUNT

38 DATEBILLED

37 OTHERCOVERAGE

AMOUNT

YES YES YES

YES

YES

YES


BIC Issue Date __________________

EVC _________________________



1

2

3

4

5

6

7

8

9

10

11

12

13

14

15





DA T E

26





CHECKNoPROVIDERNo

DATE PAGE NO




ADJUDICATED CLAIMS


1234567891 00596352

081513 1of 3


CLAIM TOTAL 13200 10100 10100


ADJUSTMENT CLAIMS

10100 8500 18600

BC




AM OUNTPAID

OTHERCOVERAGE

SHAREOF COST

ALLOWEDAM OUNT

AM OUNTBILLED

REASONCODE

STA-TUS

DATEOF SERVICE

PROCCODE

TOOTHCODE

DOCUM ENTCONTROL NO



C D1110 060113 P S019 4700 4000 4000C D1120 060113 D R019 4700 00 00


CLAIM TOTAL -19500 - 7800 - 7800


CLAIM TOTAL 19500 16300 16300





CLAIM TAR NOA


NOTICEPAGE PAGES

OF


DOCUMENTCONTROL NO

AMOUNTBILLED




ITEMINFORMATION

BLOCKCLAIMFIELDNO

CLAIMLINE


ERRORCODE

ERROR DESCRIPTION





PATIENT NAME



XSIGNATURE DATE



DENTI-CAL USE ONLY

DCN


CLAIMTYPE

PAGE PAGES

OF

CLAIMFIELD NO

CLAIMLINE

ERRORCODE


CORRECT INFORMATION




01 01

PROCEDURECODE

A

B

37B-PRL-TRN-006AC

6 PATIENT ADDRESS

9

MF-O


SERVICES

1

3

4

5

6

7

8

9

10

2

IMPORTANT NOTE

IMPORTANT NOTICE





SIGNATURE

DATE



X






DC-217 (R0909)


3 SEX

M F

4 PATIENT BIRTHDATE

MO DAY YR




CITY STATE

ZIP CODE

CHECK IF

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

P0 BOX 15610


Phone (800) 423-0507



HOW MANY_____________

11 CHECK IF

ACCIDENTINJURY

EMPLOYMENT RELATED

13 CHECK IF


14





16 CHDP CHECK IF

CHILD HEALTH AND


17 CCS


18 MF-O


SERVICES

10

OTHER ATTACHMENTS

12

ELIGIBILITY PENDING




CITY STATE ZIP CODE



1 2 3 4 5 6 7 8

BIC Issue Date ________________

EVC _______________________


26

TOOTHLTR

ARCHQUAD

27

SURFACES



29

DATE SERVICE

PERFORMED

30

QUANTITY

31

PROCEDURE

NUMBER

32

FEE

33

RENDERING

PROVIDER NO

34 COMMENTS

35

TOTAL FEE

CHARGED

36 PATIENT

SHARE-OF-COST

AMOUNT

37 OTHER

COVERAGE

AMOUNT

38

DATE BILLED

wwwdenti-calcagov




3= sex

4= Bdate= modayyr

















TX Section




BOX 33 =









image1png




FROM

TO

PAGE_____OF_____





39

X


34 COMMENTS

PO BOX 15609


Phone 800- 423- 0507


9


HOW MANY _________

10

OTHER ATTACHMENTS

41

DELETE



MO DAY YR

3 SEX

M F


23

16 CHDP


11

ACCIDENT INJURY

EMPLOYMENT RELATED

27

SUR-

FACES

28

TOOTH

NO OR

LETTER

ARCH

43 ADJ

REASON

CODE

42

ALLOWANCE

32

FEE

33 RENDERING

PROVIDER NO

31 PROCEDURE

NUMBER

30

QTY

29 DATE

SERVICE

PERFORMED

44 DATE PROSTHESIS

ORDERED

35 TOTAL FEE

CHARGED

46 TOTAL

ALLOWANCE

36 BENEFICIARY

SHARE-OF-COST

AMOUNT

38 DATE

BILLED

37 OTHER

COVERAGE

AMOUNT

YES

YES

YES

YES

YES

YES

CHECK IF

CHECK IF

CHECK IF

CHECK IF

BIC Issue Date __________________

EVC _________________________







1

2

3

4

5

6

7

8

9

10

11

12

13

14

15







BELOW IS


DATE

26

45 PROSTHESIS

LINE ITEM


111413

051314



2 DCN










Box 33=









FROM

TO

PAGE_____OF_____





39

X


34 COMMENTS

DENTI-CAL


PO BOX 15609


Phone 800- 423- 0507


9


HOW MANY _________

10

OTHER ATTACHMENTS

41

DELETE



MO DAY YR

3 SEX

M F


23

16 CHDP


11

ACCIDENT INJURY

EMPLOYMENT RELATED

27

SUR-

FACES

28

TOOTH

NO OR

LETTER

ARCH

43 ADJ

REASON

CODE

42

ALLOWANCE

32

FEE

33 RENDERING

PROVIDER NO

31 PROCEDURE

NUMBER

30

QTY

29 DATE

SERVICE

PERFORMED

44 DATE PROSTHESIS

ORDERED

35 TOTAL FEE

CHARGED

46 TOTAL

ALLOWANCE

36 BENEFICIARY

SHARE-OF-COST

AMOUNT

38 DATE

BILLED

37 OTHER

COVERAGE

AMOUNT

YES

YES

YES

YES

YES

YES

CHECK IF

CHECK IF

CHECK IF

CHECK IF

BIC Issue Date __________________

EVC _________________________







1

2

3

4

5

6

7

8

9

10

11

12

13

14

15







BELOW IS


DATE

26

45 PROSTHESIS

LINE ITEM




3 O AmalgamD2140 5500 3900 355C




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DENTI-CAL



CHECK

No

PROVIDER

No

DATE

PAGE NO


P = PAID

D = DENIED

A= ADJUSTED

PLEASE CALL (800) 423-0507


BENEFICIARY NAME

MEDI-CAL

ID NO

ADJUDICATED CLAIMS

CLAIMS SPECIFIC

NON CLAIMS SPECIFIC

1234567891

00596352

081513 1

of 3

Adams James DDS

30 Center Street

Anytown CA 95814

CLAIM TOTAL 13200 10100 10100


ADJUSTMENT CLAIMS

10100 8500 18600

B

C




BENE ID

SEX

BIRTH

DATE

AMOUNT

PAID

OTHER

COVERAGE

SHARE

OF COST

ALLOWED

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STA-

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DATE

OF SERVICE

PROC

CODE

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CODE

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CONTROL NO

AR AMOUNT

LEVY AMOUNT

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AMOUNT PAID

PAYABLES AMOUNT


C 13163108181 D0150060113 P 2500 2500 2500

C D0274060113 P 3000 1800 1800

C D0230060113 P 3000 1800 1800

C D1110060113 P S019 4700 4000 4000

C D1120060113 D R019 4700 00 00



C 13168101357 15 D7210061013 A 266B - 9500 - 00 - 00

C 14 D2140061013 A - 5000 - 3900 - 3900

C 13 D2140 061013 A - 5000 - 3900 - 3900

CLAIM TOTAL -19500 - 7800 - 7800



C 13168101357 15 D7210 061013 P 9500 8500 8500

C 14 D2140 061013 P 5000 3900 3900

C 13 D2140 061013 P 5000 3900 3900

CLAIM TOTAL 19500 16300 16300





1 Provider info

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PO BOX 15609


Phone 800-423-0507


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TAR

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NOTICE

PAGE PAGES

OF

RTD ISSUE DATE

RTD DUE DATE

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CONTROL NO

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BEGINNING

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PATIENT DENTAL

RECORD NO

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44B-PRL-TRN-006AC











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YES YES YES

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BIC Issue Date __________________

EVC _________________________



1

2

3

4

5

6

7

8

9

10

11

12

13

14

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DATE

26





15550066100



YY318100124

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46B-PRL-TRN-006AC




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BIC Issue Date __________________

EVC _________________________








1

2

3

4

5

6

7

8

9

10

11

12

13

14

15







BELOW IS


DATE

26

45 PROSTHESIS

LINE ITEM




3 O AmalgamD2140 5500 3900 355C




155500

66100



Anytown CA 95814


YY318100124

1114YY

0513YY



2 DCN










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47B-PRL-TRN-006AC








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48B-PRL-TRN-006AC








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49B-PRL-TRN-006AC

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1234567899 00596352



CLAIM TOTAL 13200 10100 10100


ADJUSTMENT CLAIMS


CLAIM TOTAL - 19500 - 7800 - 7800


CLAIM TOTAL 19500 16300 16300



10100 8500 18600


1

2

3

4

5

6 7

8

9 10 11 12 13

14 15 16 17 18 19 20 21 22 23 24

25 26 27

BC STA-

TUSDATE

OF SERVICEPROCCODE

TOOTHCODE

DOCUMENTCONTROL NO

AMOUNTPAID

OTHERCOVERAGE

SHAREOF COST

ALLOWEDAMOUNT

AMOUNTBILLED

REASONCODE

BENE ID BIRTHDATE

ADJUSTMENT AMOUNT

53B-PRL-TRN-006AC


DENTI-CAL



CHECK

No

PROVIDER

No


P = PAID

D = DENIED

A= ADJUSTED

PLEASE CALL (800) 423-0507


BENEFICIARY NAME

MEDI-CAL

ID NO

SEX

ADJUDICATED CLAIMS

CLAIMS SPECIFIC

NON CLAIMS SPECIFIC

AMOUNT PAID

PAYABLES AMOUNT

LEVY AMOUNT

AR AMOUNT

CHECK AMOUNT




1234567899

00596352

Adams James DDS

30 Center Street

Anytown CA 95814

B LAST

FIRST

99999999D 99999999D M mmddyy

C YY163108181 D0150

0601YY P

2500 2500

2500

C

D0274

0601YY P

3000 1800 1800

C

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0601YY P

3000 1800

1800

C

D1120

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4700

00 00

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4700 4000

4000

CLAIM TOTAL

13200

10100

10100


13200 10100

10100

ADJUSTMENT CLAIMS

B LAST FIRST

99999999D 99999999D F mmddyy


C YY168101357 15 D7210

0610YY A 266B - 9500 - 00

- 00

C

14 D2140

0610YY A - 5000 - 3900 - 3900

C

13 D2140

0610YY A - 5000 - 3900 - 3900

CLAIM TOTAL - 19500 - 7800 - 7800

B LAST FIRST

99999999D 99999999D F mmddyy


C YY168101357 15 D7210

0610YY P 9500 8500 8500

C

14 D2140

0610YY P 5000 3900 3900

C

13 D2140

0610YY P 5000 3900 3900

CLAIM TOTAL 19500 16300 16300



13200

18600 18600

10100 8500 18600


of 3

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

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ALLOWEDAMOUNT




005963521234567899












BC DOCUMENT

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54B-PRL-TRN-006AC

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D = DENIED

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BENE ID

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DATE

AMOUNT

PAID

ALLOWED

AMOUNT

CLAIMS SPECIFIC

NON CLAIMS SPECIFIC

AMOUNT PAID

ADJUSTMENT AMOUNT

PAYABLES AMOUNT

LEVY AMOUNT

AR AMOUNT

CHECK AMOUNT




00596352

1234567899

Adams James DDS

30 Center Street

Anytown CA 95814



----------------------------------------------------------------------------------------------------------------------------------------------------------------------






----------------------------------------------------------------------------------------------------------------------------------------------------------------------











+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++



FOR RESERVATIONS

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++



FOR RESERVATIONS

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++



FOR RESERVATIONS

B

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UNKNOWN-0


55B-PRL-TRN-006AC














56


B-PRL-TRN-006AC


CLAIM INQUIRY FORM











XSIGNATURE DATE



OPER ID ______________________________________

ACTION CODE ___________________________________

IMPORTANT


DATE BILLED

CITY STATE ZIP CODE






Anytown CA 95814

Last First

99999999999999 MM DD YY

X



MM DD YY

Mary Jones MM DD YY

57









YY30900132




7AW MM DD YYBY DATE

B-PRL-TRN-006AC


CLAIM INQUIRY FORM



PO BOX 15609


Phone 800-423-0507
















X

SIGNATURE DATE




OPER ID ______________________________________

ACTION CODE ___________________________________

IMPORTANT


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CITY STATE

ZIP CODE



Date of Service_______________________


of form







Anytown CA 95814

Last First

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MM DD YY

X




MM DD YY

Mary Jones MM DD YY




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POBOX 15609


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Anytown CA 95814

Last First

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BY DATE







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58


B-PRL-TRN-006AC


CLAIM INQUIRY FORM











XSIGNATURE DATE



OPER ID ______________________________________

ACTION CODE ___________________________________

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DATE BILLED

CITY STATE ZIP CODE






DC 003 (R 0709)



Anytown CA 95814

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59B-PRL-TRN-006AC


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PO BOX 15609


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X

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OPER ID ______________________________________

ACTION CODE ___________________________________

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Anytown CA 95814

Last First

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image1png


First Level Appeals

60B-PRL-TRN-006AC








61


B-PRL-TRN-006AC



CHECKNoPROVIDERNo





BIRTHDATE

ADJUSTMENT CLAIMS


1234567899 00596352


10100 8500 18600

CB



BENE ID

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TOOTHCODE

PROCCODE

DATEOF SERVICE

STA-TUS

REASONCODE

AMOUNTBILLED

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AMOUNTPAID




CLAIM TOTAL -19500 - 7800 - 7800


CLAIM TOTAL 19500 16300 16300





62B-PRL-TRN-006AC



CHECK

No

PROVIDER

No


of 3


P = PAID

D = DENIED

A= ADJUSTED

PLEASE CALL (800) 423-0507


BENEFICIARY NAME

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ID NO

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ADJUSTMENT CLAIMS

CLAIMS SPECIFIC

NON CLAIMS SPECIFIC

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1234567899

00596352

Adams James DDS

30 Center Street

Anytown CA 95814

10100 8500 18600

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C YY168101357 15 D7210 1010YY A 266B - 9500 - 00 - 00

C 14 D2140 1010YY A - 5000 - 3900 - 3900

C 13 D2140 1010YY A - 5000 - 3900 - 3900

CLAIM TOTAL -19500 - 7800 - 7800



C YY168101357 15 D7210 1010YY P 9500 8500 8500

C 14 D2140 1010YY P 5000 3900 3900

C 13 D2140 1010YY P 5000 3900 3900

CLAIM TOTAL 19500 16300 16300



----------------------------------------------------------------------------------------------------------------------------------







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EDI Support



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86


B-PRL-TRN-006AC


Slide Number 2

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Provider Forms

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Provider Inquiries

Slide Number 56

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Medi-Cal DentalEDI

Slide Number 75

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Slide Number 86






Sincerely


3B-PRL-TRN-006AC





Introduction



Program Overview


4B-PRL-TRN-006AC

Program Overview



5B-PRL-TRN-006AC




Whats New

Important Reminders










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11B-PRL-TRN-006AC

12B-PRL-TRN-006AC

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13B-PRL-TRN-006AC

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State of California



M mm dd yyyy








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25B-PRL-TRN-006AC



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Full Scope aid code

Child (under 21)



DDS Member









26B-PRL-TRN-006AC

Pregnant Members





27B-PRL-TRN-006AC


Overview of CalAIM




B-PRL-TRN-006AC 28


--











B-PRL-TRN-006AC 29


PROCEDURE CODE




MEMBERS OVER 21



$1800 $1350 X


$800 $600 X


1800 $1350 X


$800 $600 X



$2200 $1650 X


$12000 $9000 X


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$23000 $17250 X


$3000 $2250 X


$3000 $2250 X


$3000 $2250 X


$3000 $2250 X


$3000 $2250 X


$3000 $2250 X


$12000 $9000 X


$1000 $750 X


$4600 $3450 X

B-PRL-TRN-006AC 30





B-PRL-TRN-006AC 31





D1310



Low risk

Moderate risk

High Risk


($1500) ($4600)

D0601 D1310 6 months $6100

D0602 D1310 4 months $6100

D0603 D1310 3 months $6100

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36B-PRL-TRN-006AC


6 PATIENT ADDRESS

9


SERVICES

1

3

4

5

6

7

8

9

10

2



SIGNATURE DATE


X



DC-217 (R0909)






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YES

YES

YES

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CITY STATE ZIP CODE


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29 DATESERVICE

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35 TOTAL FEECHARGED

46 TOTALALLOWANCE


AMOUNT

38 DATEBILLED

37 OTHERCOVERAGE

AMOUNT

YES YES YES

YES

YES

YES


BIC Issue Date __________________

EVC _________________________



1

2

3

4

5

6

7

8

9

10

11

12

13

14

15





DA T E

26





CHECKNoPROVIDERNo

DATE PAGE NO




ADJUDICATED CLAIMS


1234567891 00596352

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CLAIM TOTAL 13200 10100 10100


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10100 8500 18600

BC




AM OUNTPAID

OTHERCOVERAGE

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AM OUNTBILLED

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C D1110 060113 P S019 4700 4000 4000C D1120 060113 D R019 4700 00 00


CLAIM TOTAL -19500 - 7800 - 7800


CLAIM TOTAL 19500 16300 16300





CLAIM TAR NOA


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01 01

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37B-PRL-TRN-006AC

6 PATIENT ADDRESS

9

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1

3

4

5

6

7

8

9

10

2

IMPORTANT NOTE

IMPORTANT NOTICE





SIGNATURE

DATE



X






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3 SEX

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4 PATIENT BIRTHDATE

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ZIP CODE

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YES

YES

YES

YES

YES

P0 BOX 15610


Phone (800) 423-0507



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11 CHECK IF

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13 CHECK IF


14





16 CHDP CHECK IF

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17 CCS


18 MF-O


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10

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1 2 3 4 5 6 7 8

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29

DATE SERVICE

PERFORMED

30

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31

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32

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35

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36 PATIENT

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37 OTHER

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38

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BOX 33 =









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44 DATE PROSTHESIS

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35 TOTAL FEE

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46 TOTAL

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36 BENEFICIARY

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AMOUNT

38 DATE

BILLED

37 OTHER

COVERAGE

AMOUNT

YES

YES

YES

YES

YES

YES

CHECK IF

CHECK IF

CHECK IF

CHECK IF

BIC Issue Date __________________

EVC _________________________







1

2

3

4

5

6

7

8

9

10

11

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14

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44 DATE PROSTHESIS

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35 TOTAL FEE

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46 TOTAL

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36 BENEFICIARY

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AMOUNT

38 DATE

BILLED

37 OTHER

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AMOUNT

YES

YES

YES

YES

YES

YES

CHECK IF

CHECK IF

CHECK IF

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BIC Issue Date __________________

EVC _________________________







1

2

3

4

5

6

7

8

9

10

11

12

13

14

15







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45 PROSTHESIS

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3 O AmalgamD2140 5500 3900 355C




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44 DATE PROSTHESIS

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35 TOTAL FEECHARGED

46 TOTAL

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CHECK

No

PROVIDER

No

DATE

PAGE NO


P = PAID

D = DENIED

A= ADJUSTED

PLEASE CALL (800) 423-0507


BENEFICIARY NAME

MEDI-CAL

ID NO

ADJUDICATED CLAIMS

CLAIMS SPECIFIC

NON CLAIMS SPECIFIC

1234567891

00596352

081513 1

of 3

Adams James DDS

30 Center Street

Anytown CA 95814

CLAIM TOTAL 13200 10100 10100


ADJUSTMENT CLAIMS

10100 8500 18600

B

C




BENE ID

SEX

BIRTH

DATE

AMOUNT

PAID

OTHER

COVERAGE

SHARE

OF COST

ALLOWED

AMOUNT

AMOUNT

BILLED

REASON

CODE

STA-

TUS

DATE

OF SERVICE

PROC

CODE

TOOTH

CODE

DOCUMENT

CONTROL NO

AR AMOUNT

LEVY AMOUNT

ADJUSTMENT AMOUNT

AMOUNT PAID

PAYABLES AMOUNT


C 13163108181 D0150060113 P 2500 2500 2500

C D0274060113 P 3000 1800 1800

C D0230060113 P 3000 1800 1800

C D1110060113 P S019 4700 4000 4000

C D1120060113 D R019 4700 00 00



C 13168101357 15 D7210061013 A 266B - 9500 - 00 - 00

C 14 D2140061013 A - 5000 - 3900 - 3900

C 13 D2140 061013 A - 5000 - 3900 - 3900

CLAIM TOTAL -19500 - 7800 - 7800



C 13168101357 15 D7210 061013 P 9500 8500 8500

C 14 D2140 061013 P 5000 3900 3900

C 13 D2140 061013 P 5000 3900 3900

CLAIM TOTAL 19500 16300 16300





1 Provider info

2 Check






PO BOX 15609


Phone 800-423-0507


CLAIM

TAR

NOA






NOTICE

PAGE PAGES

OF

RTD ISSUE DATE

RTD DUE DATE

DOCUMENT

CONTROL NO

AMOUNT

BILLED

BEGINNING

DATE OF SERVICE

PATIENT DENTAL

RECORD NO

PATIENT MEDI-CAL

ID NUMBER

PATIENT NAME

ITEM

INFORMATION

BLOCK

CLAIM

FIELD

NO

CLAIM

LINE

SUBMITTED

INFORMATION

ERROR

CODE

ERROR DESCRIPTION

RETAIN THIS PORTION





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X

SIGNATURE

DATE





DENTI-CAL USE ONLY

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TYPE

PAGE

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FIELD NO

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CORRECT INFORMATION



MAILING ADDRESS

CITY STATE ZIP CODE


01 01

PROCEDURE

CODE

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B

10






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38B-PRL-TRN-006AC






39B-PRL-TRN-006AC












40B-PRL-TRN-006AC

6 PATIENT ADDRESS

9


SERVICES

1

3

4

5

6

7

8

9

10

2


SIGNATURE DATE


X



DC-217 (R 1019)






CHECK IF YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES



HOW MANY_____________

11 CHECK IF

ACCIDENTINJURY

EMPLOYMENT RELATED









SERVICES






CITY STATE ZIP CODE


1 2 3 4 5 6 7 8

BIC Issue Date ________________

EVC _______________________


27 SURFACES



30 QUANTITY

31 PROCEDURE

NUMBER

32 FEE

33 RENDERING

PROVIDER NPI



AMOUNT

37 OTHER COVERAGE

AMOUNT

38 DATE BILLED


Address

Address 00000

40900

MM DD YY

X

3

X






ANYTOWN CA 95814

mmddyy

123456789A1

41B-PRL-TRN-006AC

6 PATIENT ADDRESS

9

MF-O


SERVICES

1

3

4

5

6

7

8

9

10

2

IMPORTANT NOTICE



SIGNATURE

DATE



X






DC-217 (R 1019)


3 SEX

M F

4 PATIENT BIRTHDATE

MO DAY YR




CITY STATE

ZIP CODE

CHECK IF

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

P0 BOX 15610


Phone (800) 423-0507



HOW MANY_____________

11 CHECK IF

ACCIDENTINJURY

EMPLOYMENT RELATED

13 CHECK IF


14





16 CHDP CHECK IF

CHILD HEALTH AND


17 CCS


18 MF-O


SERVICES

10

OTHER ATTACHMENTS

12

ELIGIBILITY PENDING




CITY STATE ZIP CODE



1 2 3 4 5 6 7 8

BIC Issue Date ________________

EVC _______________________


26

TOOTHLTR

ARCHQUAD

27

SURFACES



29

DATE SERVICE

PERFORMED

30

QUANTITY

31

PROCEDURE

NUMBER

32

FEE

33

RENDERING

PROVIDER NPI

34 COMMENTS

35

TOTAL FEE

CHARGED

36 PATIENT

SHARE-OF-COST

AMOUNT

37 OTHER

COVERAGE

AMOUNT

38

DATE BILLED


Address

Address 00000

40900

MM DD YY

X

3

X

Exam MM DD YY D0150 2500 9912345678








ANYTOWN CA 95814




3= sex

4= Bdate= modayyr

















TX Section




BOX 33 =






BILLING LIMITATIONS



image1png





3SEXM F






6PATIENT ADDRESS

CITY STATE

9 YESCHECK IF


HOW MANY_____________

YES

11ACCIDENTINJURY

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YES

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YES

16

17

18





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HOSPITALIN-PATIENT




28 32FEE

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CHECK IF CHECK IF

1

3

4

5

6

7

8

9

10

2


36

37

38 DATEBILLED


SIGNATURE DATE


X



SERVICES



10

OTHER ATTACHMENTS


EVC 123456789A1

1 2 3 4 5 6 7 8


27SURFACES

30QUANTITY

31PROCEDURE

NUMBER



AMOUNT

35


OTHER COVERAGE

AMOUNT


Address

Address 00000



ANYTOWN CA 95814

Mary Smith MM DD YY

Prophy MM DD YY D1110 8500 9912345678

8500

MM DD YY

DC-217 (R 1019)

1

1 2

3

4

42B-PRL-TRN-006AC

PO BOX 15610


Phone 800-423-0507


3SEX

M F

4PATIENT BIRTHDATE

MO DAY YR



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6PATIENT ADDRESS

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9

YES

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13


14





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16

17

18

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CHILD HEALTH AND


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YES



21 MAILING ADDRESS

TELEPHONE NUMBER

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CITY STATE

ZIP CODE

22 PLACE OF SERVICE


HOSPITAL

IN-PATIENT

HOSPITAL

OUT-PATIENT

OTHER

(PLEASE SPECIFY)


26

TOOTHLTR

ARCHQUAD

28

32

FEE

33

RENDERING

PROVIDER NPI

CHECK IF

CHECK IF

1

3

4

5

6

7

8

9

10

2

34 COMMENTS

TOTAL FEE

CHARGED

36

37

38

DATE

BILLED

IMPORTANT NOTE

IMPORTANT NOTICE



SIGNATURE

DATE



X


MF-O


SERVICES

12

ELIGIBILITY PENDING


10

OTHER ATTACHMENTS


EVC 123456789A1

1 2 3 4 5 6 7 8



27

SURFACES

30

QUANTITY

31

PROCEDURE

NUMBER

29

DATE SERVICE

PERFORMED

PATIENT

SHARE- OF- COST

AMOUNT

35





OTHER

COVERAGE

AMOUNT


Address

Address 00000



ANYTOWN CA 95814

Mary Smith MM DD YY

Prophy MM DD YY D1110 8500 9912345678

8500

MM DD YY

DC-217 (R 1019)

image1png

6 PATIENT ADDRESS

9


SERVICES

1

3

4

5

6

7

8

9

10

2

IMPORTANT NOTE

SIGNATURE DATE


X



DC-217 (R 1019)






CHECK IF YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES



HOW MANY_____________

11 CHECK IF

ACCIDENTINJURY

EMPLOYMENT RELATED









SERVICES






CITY STATE ZIP CODE


1 2 3 4 5 6 7 8

BIC Issue Date ________________

EVC _______________________


27 SURFACES



30 QUANTITY

31 PROCEDURE

NUMBER

32 FEE

33 RENDERING

PROVIDER NPI



AMOUNT

37 OTHER COVERAGE

AMOUNT

38 DATE BILLED


Address

Address 00000

X

9

X


Anytown CA 95814



80000

MM DD YY

Mary Smith MM DD YY

X



43B-PRL-TRN-006AC

6 PATIENT ADDRESS

9

MF-O


SERVICES

1

3

4

5

6

7

8

9

10

2

IMPORTANT NOTE

SIGNATURE

DATE



X






DC-217 (R 1019)


3 SEX

M F

4 PATIENT BIRTHDATE

MO DAY YR




CITY STATE

ZIP CODE

CHECK IF

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

P0 BOX 15610


Phone (800) 423-0507



HOW MANY_____________

11 CHECK IF

ACCIDENTINJURY

EMPLOYMENT RELATED

13 CHECK IF


14





16 CHDP CHECK IF

CHILD HEALTH AND


17 CCS


18 MF-O


SERVICES

10

OTHER ATTACHMENTS

12

ELIGIBILITY PENDING




CITY STATE ZIP CODE



1 2 3 4 5 6 7 8

BIC Issue Date ________________

EVC _______________________


26

TOOTHLTR

ARCHQUAD

27

SURFACES



29

DATE SERVICE

PERFORMED

30

QUANTITY

31

PROCEDURE

NUMBER

32

FEE

33

RENDERING

PROVIDER NPI

34 COMMENTS

35

TOTAL FEE

CHARGED

36 PATIENT

SHARE-OF-COST

AMOUNT

37 OTHER

COVERAGE

AMOUNT

38

DATE BILLED


Address

Address 00000

X

9

X


Anytown CA 95814





80000

MM DD YY

Mary Smith MM DD YY

X

IMPORTANT NOTICE






- TX section






image1png













44B-PRL-TRN-006AC











45B-PRL-TRN-006AC






39

X


34 COMMENTS




HOW MANY _________


41DELETE


3 SEXM F


23

16 CHDP


EMPLOYMENT RELATED

27SUR-FACES

28TOOTHNO OR

LETTERARCH

43 ADJREASON

CODE42ALLOWANCE

32FEE


31 PROCEDURENUMBER

30QTY

29 DATESERVICE

PERFORMED


35 TOTAL FEECHARGED

46 TOTALALLOWANCE


AMOUNT

38 DATEBILLED

37 OTHERCOVERAGE

AMOUNT

YES YES YES

YES

YES

YES


BIC Issue Date __________________

EVC _________________________



1

2

3

4

5

6

7

8

9

10

11

12

13

14

15





DATE

26





15550066100



YY318100124

1114YY0513YY

46B-PRL-TRN-006AC




FROM

TO

PAGE_____OF_____





39

X


34 COMMENTS

PO BOX 15609


Phone 800-423-0507


9


HOW MANY _________

10

OTHER ATTACHMENTS

41

DELETE



MO DAY YR

3 SEX

M F


23

16 CHDP


11

ACCIDENT INJURY

EMPLOYMENT RELATED

27

SUR-

FACES

28

TOOTH

NO OR

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43 ADJ

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32

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33 RENDERING

PROVIDER NO

31 PROCEDURE

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29 DATE

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PERFORMED

44 DATE PROSTHESIS

ORDERED

35 TOTAL FEE

CHARGED

46 TOTAL

ALLOWANCE

36 BENEFICIARY

SHARE-OF-COST

AMOUNT

38 DATE

BILLED

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COVERAGE

AMOUNT

YES

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YES

YES

YES

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CHECK IF

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CHECK IF

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BIC Issue Date __________________

EVC _________________________








1

2

3

4

5

6

7

8

9

10

11

12

13

14

15







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DATE

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45 PROSTHESIS

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ADJUDICATED CLAIMS





1234567899 00596352



CLAIM TOTAL 13200 10100 10100


ADJUSTMENT CLAIMS


CLAIM TOTAL - 19500 - 7800 - 7800


CLAIM TOTAL 19500 16300 16300



10100 8500 18600


1

2

3

4

5

6 7

8

9 10 11 12 13

14 15 16 17 18 19 20 21 22 23 24

25 26 27

BC STA-

TUSDATE

OF SERVICEPROCCODE

TOOTHCODE

DOCUMENTCONTROL NO

AMOUNTPAID

OTHERCOVERAGE

SHAREOF COST

ALLOWEDAMOUNT

AMOUNTBILLED

REASONCODE

BENE ID BIRTHDATE

ADJUSTMENT AMOUNT

53B-PRL-TRN-006AC


DENTI-CAL



CHECK

No

PROVIDER

No


P = PAID

D = DENIED

A= ADJUSTED

PLEASE CALL (800) 423-0507


BENEFICIARY NAME

MEDI-CAL

ID NO

SEX

ADJUDICATED CLAIMS

CLAIMS SPECIFIC

NON CLAIMS SPECIFIC

AMOUNT PAID

PAYABLES AMOUNT

LEVY AMOUNT

AR AMOUNT

CHECK AMOUNT




1234567899

00596352

Adams James DDS

30 Center Street

Anytown CA 95814

B LAST

FIRST

99999999D 99999999D M mmddyy

C YY163108181 D0150

0601YY P

2500 2500

2500

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1800

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CLAIM TOTAL

13200

10100

10100


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B LAST FIRST

99999999D 99999999D F mmddyy


C YY168101357 15 D7210

0610YY A 266B - 9500 - 00

- 00

C

14 D2140

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C

13 D2140

0610YY A - 5000 - 3900 - 3900

CLAIM TOTAL - 19500 - 7800 - 7800

B LAST FIRST

99999999D 99999999D F mmddyy


C YY168101357 15 D7210

0610YY P 9500 8500 8500

C

14 D2140

0610YY P 5000 3900 3900

C

13 D2140

0610YY P 5000 3900 3900

CLAIM TOTAL 19500 16300 16300



13200

18600 18600

10100 8500 18600


of 3

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

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C

STA-

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OF SERVICE

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CODE

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AMOUNT

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OTHER

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SHARE

OF COST

ALLOWED

AMOUNT

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CHECKNoPROVIDER

No






AMOUNTPAID

ALLOWEDAMOUNT




005963521234567899












BC DOCUMENT

CONTROL NOOTHER

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OF COSTAMOUNTBILLED

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54B-PRL-TRN-006AC

OTHER

COVERAGE

SHARE

OF COST

AMOUNT

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DATE

OF SERVICE

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CODE

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CODE


DENTI-CAL



CHECK

No

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No


of 3


P = PAID

D = DENIED

A= ADJUSTED

PLEASE CALL (800) 423-0507


BENEFICIARY NAME

MEDI-CAL

ID NO

BENE ID

SEX

BIRTH

DATE

AMOUNT

PAID

ALLOWED

AMOUNT

CLAIMS SPECIFIC

NON CLAIMS SPECIFIC

AMOUNT PAID

ADJUSTMENT AMOUNT

PAYABLES AMOUNT

LEVY AMOUNT

AR AMOUNT

CHECK AMOUNT




00596352

1234567899

Adams James DDS

30 Center Street

Anytown CA 95814



----------------------------------------------------------------------------------------------------------------------------------------------------------------------






----------------------------------------------------------------------------------------------------------------------------------------------------------------------











+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++



FOR RESERVATIONS

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++



FOR RESERVATIONS

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++



FOR RESERVATIONS

B

C

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55B-PRL-TRN-006AC














56


B-PRL-TRN-006AC


CLAIM INQUIRY FORM











XSIGNATURE DATE



OPER ID ______________________________________

ACTION CODE ___________________________________

IMPORTANT


DATE BILLED

CITY STATE ZIP CODE






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Last First

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MM DD YY

Mary Jones MM DD YY

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B-PRL-TRN-006AC


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PO BOX 15609


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SIGNATURE DATE




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Last First

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58


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60B-PRL-TRN-006AC








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CLAIM TOTAL -19500 - 7800 - 7800


CLAIM TOTAL 19500 16300 16300





62B-PRL-TRN-006AC



CHECK

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D = DENIED

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PLEASE CALL (800) 423-0507


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ID NO

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NON CLAIMS SPECIFIC

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1234567899

00596352

Adams James DDS

30 Center Street

Anytown CA 95814

10100 8500 18600

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CLAIM TOTAL -19500 - 7800 - 7800



C YY168101357 15 D7210 1010YY P 9500 8500 8500

C 14 D2140 1010YY P 5000 3900 3900

C 13 D2140 1010YY P 5000 3900 3900

CLAIM TOTAL 19500 16300 16300



----------------------------------------------------------------------------------------------------------------------------------







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B-PRL-TRN-006AC










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71B-PRL-TRN-006AC








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B-PRL-TRN-006AC








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10 5













86


B-PRL-TRN-006AC


Slide Number 2

Slide Number 3


Slide Number 5

Slide Number 6

Slide Number 7

Slide Number 8

Slide Number 9



Slide Number 12


Slide Number 14


Slide Number 16

Slide Number 17

Slide Number 18

Slide Number 19

Slide Number 20

Slide Number 21

Slide Number 22

Slide Number 23

Slide Number 24

Slide Number 25

Slide Number 26

Slide Number 27

Slide Number 28

Slide Number 29

Slide Number 30

Slide Number 31

Slide Number 32

Slide Number 33

Slide Number 34

Slide Number 35


Provider Forms

Slide Number 38



Slide Number 41

Slide Number 42

Slide Number 43



Slide Number 46




Slide Number 50


Slide Number 52

Slide Number 53

Slide Number 54

Provider Inquiries

Slide Number 56

Slide Number 57

Slide Number 58

Slide Number 59



Slide Number 62

Slide Number 63

Slide Number 64

Slide Number 65

Slide Number 66

Slide Number 67

Slide Number 68

Slide Number 69

Slide Number 70

Slide Number 71

Slide Number 72

Slide Number 73

Medi-Cal DentalEDI

Slide Number 75

Slide Number 76

Slide Number 77

Slide Number 78

Slide Number 79

Slide Number 80

Slide Number 81

Slide Number 82

Slide Number 83

Slide Number 84

Slide Number 85

Slide Number 86


Introduction



Program Overview


4B-PRL-TRN-006AC

Program Overview



5B-PRL-TRN-006AC




Whats New

Important Reminders










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12B-PRL-TRN-006AC

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26B-PRL-TRN-006AC

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27B-PRL-TRN-006AC


Overview of CalAIM




B-PRL-TRN-006AC 28


--











B-PRL-TRN-006AC 29


PROCEDURE CODE




MEMBERS OVER 21



$1800 $1350 X


$800 $600 X


1800 $1350 X


$800 $600 X



$2200 $1650 X


$12000 $9000 X


$20000 $15000 X


$20000 $15000 X


$23000 $17250 X


$23000 $17250 X


$3000 $2250 X


$3000 $2250 X


$3000 $2250 X


$3000 $2250 X


$3000 $2250 X


$3000 $2250 X


$12000 $9000 X


$1000 $750 X


$4600 $3450 X

B-PRL-TRN-006AC 30





B-PRL-TRN-006AC 31





D1310



Low risk

Moderate risk

High Risk


($1500) ($4600)

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36B-PRL-TRN-006AC


6 PATIENT ADDRESS

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4

5

6

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8

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SIGNATURE DATE


X



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31 PROCEDURENUM BER

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29 DATESERVICE

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35 TOTAL FEECHARGED

46 TOTALALLOWANCE


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38 DATEBILLED

37 OTHERCOVERAGE

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BIC Issue Date __________________

EVC _________________________



1

2

3

4

5

6

7

8

9

10

11

12

13

14

15





DA T E

26





CHECKNoPROVIDERNo

DATE PAGE NO




ADJUDICATED CLAIMS


1234567891 00596352

081513 1of 3


CLAIM TOTAL 13200 10100 10100


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10100 8500 18600

BC




AM OUNTPAID

OTHERCOVERAGE

SHAREOF COST

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STA-TUS

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C D1110 060113 P S019 4700 4000 4000C D1120 060113 D R019 4700 00 00


CLAIM TOTAL -19500 - 7800 - 7800


CLAIM TOTAL 19500 16300 16300





CLAIM TAR NOA


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1

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4

5

6

7

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9

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17 CCS


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1 2 3 4 5 6 7 8

BIC Issue Date ________________

EVC _______________________


26

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27

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29

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PERFORMED

30

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31

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NUMBER

32

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36 PATIENT

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38

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BOX 33 =









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16 CHDP


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27

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44 DATE PROSTHESIS

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35 TOTAL FEE

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46 TOTAL

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36 BENEFICIARY

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38 DATE

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37 OTHER

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YES

YES

YES

YES

YES

YES

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CHECK IF

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BIC Issue Date __________________

EVC _________________________







1

2

3

4

5

6

7

8

9

10

11

12

13

14

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26

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44 DATE PROSTHESIS

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35 TOTAL FEE

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46 TOTAL

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36 BENEFICIARY

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38 DATE

BILLED

37 OTHER

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BIC Issue Date __________________

EVC _________________________







1

2

3

4

5

6

7

8

9

10

11

12

13

14

15







BELOW IS


DATE

26

45 PROSTHESIS

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3 O AmalgamD2140 5500 3900 355C




155500

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Anytown CA 95814


10318100124

111410

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HOW MANY _________


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D = DENIED

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PLEASE CALL (800) 423-0507


BENEFICIARY NAME

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ID NO

ADJUDICATED CLAIMS

CLAIMS SPECIFIC

NON CLAIMS SPECIFIC

1234567891

00596352

081513 1

of 3

Adams James DDS

30 Center Street

Anytown CA 95814

CLAIM TOTAL 13200 10100 10100


ADJUSTMENT CLAIMS

10100 8500 18600

B

C




BENE ID

SEX

BIRTH

DATE

AMOUNT

PAID

OTHER

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C D0274060113 P 3000 1800 1800

C D0230060113 P 3000 1800 1800

C D1110060113 P S019 4700 4000 4000

C D1120060113 D R019 4700 00 00



C 13168101357 15 D7210061013 A 266B - 9500 - 00 - 00

C 14 D2140061013 A - 5000 - 3900 - 3900

C 13 D2140 061013 A - 5000 - 3900 - 3900

CLAIM TOTAL -19500 - 7800 - 7800



C 13168101357 15 D7210 061013 P 9500 8500 8500

C 14 D2140 061013 P 5000 3900 3900

C 13 D2140 061013 P 5000 3900 3900

CLAIM TOTAL 19500 16300 16300





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PAGE PAGES

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1

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1

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1234567899 00596352



CLAIM TOTAL 13200 10100 10100


ADJUSTMENT CLAIMS


CLAIM TOTAL - 19500 - 7800 - 7800


CLAIM TOTAL 19500 16300 16300



10100 8500 18600


1

2

3

4

5

6 7

8

9 10 11 12 13

14 15 16 17 18 19 20 21 22 23 24

25 26 27

BC STA-

TUSDATE

OF SERVICEPROCCODE

TOOTHCODE

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AMOUNTPAID

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BENE ID BIRTHDATE

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53B-PRL-TRN-006AC


DENTI-CAL



CHECK

No

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P = PAID

D = DENIED

A= ADJUSTED

PLEASE CALL (800) 423-0507


BENEFICIARY NAME

MEDI-CAL

ID NO

SEX

ADJUDICATED CLAIMS

CLAIMS SPECIFIC

NON CLAIMS SPECIFIC

AMOUNT PAID

PAYABLES AMOUNT

LEVY AMOUNT

AR AMOUNT

CHECK AMOUNT




1234567899

00596352

Adams James DDS

30 Center Street

Anytown CA 95814

B LAST

FIRST

99999999D 99999999D M mmddyy

C YY163108181 D0150

0601YY P

2500 2500

2500

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0601YY P

3000 1800 1800

C

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0601YY P

3000 1800

1800

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CLAIM TOTAL

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10100

10100


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B LAST FIRST

99999999D 99999999D F mmddyy


C YY168101357 15 D7210

0610YY A 266B - 9500 - 00

- 00

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14 D2140

0610YY A - 5000 - 3900 - 3900

C

13 D2140

0610YY A - 5000 - 3900 - 3900

CLAIM TOTAL - 19500 - 7800 - 7800

B LAST FIRST

99999999D 99999999D F mmddyy


C YY168101357 15 D7210

0610YY P 9500 8500 8500

C

14 D2140

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13 D2140

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CLAIM TOTAL 19500 16300 16300



13200

18600 18600

10100 8500 18600


of 3

1

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3

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9

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11

12

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005963521234567899












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ALLOWED

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CLAIMS SPECIFIC

NON CLAIMS SPECIFIC

AMOUNT PAID

ADJUSTMENT AMOUNT

PAYABLES AMOUNT

LEVY AMOUNT

AR AMOUNT

CHECK AMOUNT




00596352

1234567899

Adams James DDS

30 Center Street

Anytown CA 95814



----------------------------------------------------------------------------------------------------------------------------------------------------------------------






----------------------------------------------------------------------------------------------------------------------------------------------------------------------











+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++



FOR RESERVATIONS

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++



FOR RESERVATIONS

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++



FOR RESERVATIONS

B

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55B-PRL-TRN-006AC














56


B-PRL-TRN-006AC


CLAIM INQUIRY FORM











XSIGNATURE DATE



OPER ID ______________________________________

ACTION CODE ___________________________________

IMPORTANT


DATE BILLED

CITY STATE ZIP CODE






Anytown CA 95814

Last First

99999999999999 MM DD YY

X



MM DD YY

Mary Jones MM DD YY

57









YY30900132




7AW MM DD YYBY DATE

B-PRL-TRN-006AC


CLAIM INQUIRY FORM



PO BOX 15609


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X

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OPER ID ______________________________________

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ZIP CODE



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Last First

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MM DD YY

Mary Jones MM DD YY




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Last First

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BY DATE







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58


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XSIGNATURE DATE



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59B-PRL-TRN-006AC


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Last First

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First Level Appeals

60B-PRL-TRN-006AC








61


B-PRL-TRN-006AC



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BIRTHDATE

ADJUSTMENT CLAIMS


1234567899 00596352


10100 8500 18600

CB



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TOOTHCODE

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STA-TUS

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AMOUNTPAID




CLAIM TOTAL -19500 - 7800 - 7800


CLAIM TOTAL 19500 16300 16300





62B-PRL-TRN-006AC



CHECK

No

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of 3


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D = DENIED

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1234567899

00596352

Adams James DDS

30 Center Street

Anytown CA 95814

10100 8500 18600

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C 14 D2140 1010YY A - 5000 - 3900 - 3900

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CLAIM TOTAL -19500 - 7800 - 7800



C YY168101357 15 D7210 1010YY P 9500 8500 8500

C 14 D2140 1010YY P 5000 3900 3900

C 13 D2140 1010YY P 5000 3900 3900

CLAIM TOTAL 19500 16300 16300



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Senate Bill 639






36B-PRL-TRN-006AC


6 PATIENT ADDRESS

9


SERVICES

1

3

4

5

6

7

8

9

10

2



SIGNATURE DATE


X



DC-217 (R0909)






CHECK IF YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES



HOW M ANY_____________

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CITY STATE ZIP CODE


BIC Issue Date ________________

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27 SURFACES



30 Q UANTI TY

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31 PROCEDURENUM BER

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29 DATESERVICE

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35 TOTAL FEECHARGED

46 TOTALALLOWANCE


AMOUNT

38 DATEBILLED

37 OTHERCOVERAGE

AMOUNT

YES YES YES

YES

YES

YES


BIC Issue Date __________________

EVC _________________________



1

2

3

4

5

6

7

8

9

10

11

12

13

14

15





DA T E

26





CHECKNoPROVIDERNo

DATE PAGE NO




ADJUDICATED CLAIMS


1234567891 00596352

081513 1of 3


CLAIM TOTAL 13200 10100 10100


ADJUSTMENT CLAIMS

10100 8500 18600

BC




AM OUNTPAID

OTHERCOVERAGE

SHAREOF COST

ALLOWEDAM OUNT

AM OUNTBILLED

REASONCODE

STA-TUS

DATEOF SERVICE

PROCCODE

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DOCUM ENTCONTROL NO



C D1110 060113 P S019 4700 4000 4000C D1120 060113 D R019 4700 00 00


CLAIM TOTAL -19500 - 7800 - 7800


CLAIM TOTAL 19500 16300 16300





CLAIM TAR NOA


NOTICEPAGE PAGES

OF


DOCUMENTCONTROL NO

AMOUNTBILLED




ITEMINFORMATION

BLOCKCLAIMFIELDNO

CLAIMLINE


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CLAIMTYPE

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01 01

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37B-PRL-TRN-006AC

6 PATIENT ADDRESS

9

MF-O


SERVICES

1

3

4

5

6

7

8

9

10

2

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IMPORTANT NOTICE





SIGNATURE

DATE



X






DC-217 (R0909)


3 SEX

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4 PATIENT BIRTHDATE

MO DAY YR




CITY STATE

ZIP CODE

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YES

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P0 BOX 15610


Phone (800) 423-0507



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11 CHECK IF

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13 CHECK IF


14





16 CHDP CHECK IF

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17 CCS


18 MF-O


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10

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ELIGIBILITY PENDING




CITY STATE ZIP CODE



1 2 3 4 5 6 7 8

BIC Issue Date ________________

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26

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29

DATE SERVICE

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30

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31

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34 COMMENTS

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36 PATIENT

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37 OTHER

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BOX 33 =









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35 TOTAL FEE

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46 TOTAL

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36 BENEFICIARY

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38 DATE

BILLED

37 OTHER

COVERAGE

AMOUNT

YES

YES

YES

YES

YES

YES

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BIC Issue Date __________________

EVC _________________________







1

2

3

4

5

6

7

8

9

10

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14

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44 DATE PROSTHESIS

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35 TOTAL FEE

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46 TOTAL

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36 BENEFICIARY

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AMOUNT

38 DATE

BILLED

37 OTHER

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YES

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YES

YES

YES

YES

CHECK IF

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BIC Issue Date __________________

EVC _________________________







1

2

3

4

5

6

7

8

9

10

11

12

13

14

15







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45 PROSTHESIS

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44 DATE PROSTHESIS

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35 TOTAL FEECHARGED

46 TOTAL

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36 BENEFICIARY

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38 DATEBILLED






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CHECK

No

PROVIDER

No

DATE

PAGE NO


P = PAID

D = DENIED

A= ADJUSTED

PLEASE CALL (800) 423-0507


BENEFICIARY NAME

MEDI-CAL

ID NO

ADJUDICATED CLAIMS

CLAIMS SPECIFIC

NON CLAIMS SPECIFIC

1234567891

00596352

081513 1

of 3

Adams James DDS

30 Center Street

Anytown CA 95814

CLAIM TOTAL 13200 10100 10100


ADJUSTMENT CLAIMS

10100 8500 18600

B

C




BENE ID

SEX

BIRTH

DATE

AMOUNT

PAID

OTHER

COVERAGE

SHARE

OF COST

ALLOWED

AMOUNT

AMOUNT

BILLED

REASON

CODE

STA-

TUS

DATE

OF SERVICE

PROC

CODE

TOOTH

CODE

DOCUMENT

CONTROL NO

AR AMOUNT

LEVY AMOUNT

ADJUSTMENT AMOUNT

AMOUNT PAID

PAYABLES AMOUNT


C 13163108181 D0150060113 P 2500 2500 2500

C D0274060113 P 3000 1800 1800

C D0230060113 P 3000 1800 1800

C D1110060113 P S019 4700 4000 4000

C D1120060113 D R019 4700 00 00



C 13168101357 15 D7210061013 A 266B - 9500 - 00 - 00

C 14 D2140061013 A - 5000 - 3900 - 3900

C 13 D2140 061013 A - 5000 - 3900 - 3900

CLAIM TOTAL -19500 - 7800 - 7800



C 13168101357 15 D7210 061013 P 9500 8500 8500

C 14 D2140 061013 P 5000 3900 3900

C 13 D2140 061013 P 5000 3900 3900

CLAIM TOTAL 19500 16300 16300





1 Provider info

2 Check






PO BOX 15609


Phone 800-423-0507


CLAIM

TAR

NOA






NOTICE

PAGE PAGES

OF

RTD ISSUE DATE

RTD DUE DATE

DOCUMENT

CONTROL NO

AMOUNT

BILLED

BEGINNING

DATE OF SERVICE

PATIENT DENTAL

RECORD NO

PATIENT MEDI-CAL

ID NUMBER

PATIENT NAME

ITEM

INFORMATION

BLOCK

CLAIM

FIELD

NO

CLAIM

LINE

SUBMITTED

INFORMATION

ERROR

CODE

ERROR DESCRIPTION

RETAIN THIS PORTION





PATIENT NAME






X

SIGNATURE

DATE





DENTI-CAL USE ONLY

DCN


CLAIM

TYPE

PAGE

PAGES

OF

CLAIM

FIELD NO

CLAIM

LINE

ERROR

CODE




CORRECT INFORMATION



MAILING ADDRESS

CITY STATE ZIP CODE


01 01

PROCEDURE

CODE

A

B

10






image1png

































38B-PRL-TRN-006AC






39B-PRL-TRN-006AC












40B-PRL-TRN-006AC

6 PATIENT ADDRESS

9


SERVICES

1

3

4

5

6

7

8

9

10

2


SIGNATURE DATE


X



DC-217 (R 1019)






CHECK IF YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES



HOW MANY_____________

11 CHECK IF

ACCIDENTINJURY

EMPLOYMENT RELATED









SERVICES






CITY STATE ZIP CODE


1 2 3 4 5 6 7 8

BIC Issue Date ________________

EVC _______________________


27 SURFACES



30 QUANTITY

31 PROCEDURE

NUMBER

32 FEE

33 RENDERING

PROVIDER NPI



AMOUNT

37 OTHER COVERAGE

AMOUNT

38 DATE BILLED


Address

Address 00000

40900

MM DD YY

X

3

X






ANYTOWN CA 95814

mmddyy

123456789A1

41B-PRL-TRN-006AC

6 PATIENT ADDRESS

9

MF-O


SERVICES

1

3

4

5

6

7

8

9

10

2

IMPORTANT NOTICE



SIGNATURE

DATE



X






DC-217 (R 1019)


3 SEX

M F

4 PATIENT BIRTHDATE

MO DAY YR




CITY STATE

ZIP CODE

CHECK IF

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

P0 BOX 15610


Phone (800) 423-0507



HOW MANY_____________

11 CHECK IF

ACCIDENTINJURY

EMPLOYMENT RELATED

13 CHECK IF


14





16 CHDP CHECK IF

CHILD HEALTH AND


17 CCS


18 MF-O


SERVICES

10

OTHER ATTACHMENTS

12

ELIGIBILITY PENDING




CITY STATE ZIP CODE



1 2 3 4 5 6 7 8

BIC Issue Date ________________

EVC _______________________


26

TOOTHLTR

ARCHQUAD

27

SURFACES



29

DATE SERVICE

PERFORMED

30

QUANTITY

31

PROCEDURE

NUMBER

32

FEE

33

RENDERING

PROVIDER NPI

34 COMMENTS

35

TOTAL FEE

CHARGED

36 PATIENT

SHARE-OF-COST

AMOUNT

37 OTHER

COVERAGE

AMOUNT

38

DATE BILLED


Address

Address 00000

40900

MM DD YY

X

3

X

Exam MM DD YY D0150 2500 9912345678








ANYTOWN CA 95814




3= sex

4= Bdate= modayyr

















TX Section




BOX 33 =






BILLING LIMITATIONS



image1png





3SEXM F






6PATIENT ADDRESS

CITY STATE

9 YESCHECK IF


HOW MANY_____________

YES

11ACCIDENTINJURY

EMPLOYMENT RELATED

CHECK IF YES

YES

YES





YES

YES

YES

16

17

18





SERVICES

YES

YES

YES





HOSPITALIN-PATIENT




28 32FEE

33RENDERING

PROVIDER NPI

CHECK IF CHECK IF

1

3

4

5

6

7

8

9

10

2


36

37

38 DATEBILLED


SIGNATURE DATE


X



SERVICES



10

OTHER ATTACHMENTS


EVC 123456789A1

1 2 3 4 5 6 7 8


27SURFACES

30QUANTITY

31PROCEDURE

NUMBER



AMOUNT

35


OTHER COVERAGE

AMOUNT


Address

Address 00000



ANYTOWN CA 95814

Mary Smith MM DD YY

Prophy MM DD YY D1110 8500 9912345678

8500

MM DD YY

DC-217 (R 1019)

1

1 2

3

4

42B-PRL-TRN-006AC

PO BOX 15610


Phone 800-423-0507


3SEX

M F

4PATIENT BIRTHDATE

MO DAY YR



ZIP CODE



6PATIENT ADDRESS

CITY STATE

9

YES

CHECK IF


HOW MANY_____________

YES

11

ACCIDENTINJURY

EMPLOYMENT RELATED

CHECK IF

YES

YES

YES

13


14





YES

YES

YES

16

17

18

CHDP

CHILD HEALTH AND


ccs


MF-O


SERVICES

YES

YES

YES



21 MAILING ADDRESS

TELEPHONE NUMBER

( )

CITY STATE

ZIP CODE

22 PLACE OF SERVICE


HOSPITAL

IN-PATIENT

HOSPITAL

OUT-PATIENT

OTHER

(PLEASE SPECIFY)


26

TOOTHLTR

ARCHQUAD

28

32

FEE

33

RENDERING

PROVIDER NPI

CHECK IF

CHECK IF

1

3

4

5

6

7

8

9

10

2

34 COMMENTS

TOTAL FEE

CHARGED

36

37

38

DATE

BILLED

IMPORTANT NOTE

IMPORTANT NOTICE



SIGNATURE

DATE



X


MF-O


SERVICES

12

ELIGIBILITY PENDING


10

OTHER ATTACHMENTS


EVC 123456789A1

1 2 3 4 5 6 7 8



27

SURFACES

30

QUANTITY

31

PROCEDURE

NUMBER

29

DATE SERVICE

PERFORMED

PATIENT

SHARE- OF- COST

AMOUNT

35





OTHER

COVERAGE

AMOUNT


Address

Address 00000



ANYTOWN CA 95814

Mary Smith MM DD YY

Prophy MM DD YY D1110 8500 9912345678

8500

MM DD YY

DC-217 (R 1019)

image1png

6 PATIENT ADDRESS

9


SERVICES

1

3

4

5

6

7

8

9

10

2

IMPORTANT NOTE

SIGNATURE DATE


X



DC-217 (R 1019)






CHECK IF YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES



HOW MANY_____________

11 CHECK IF

ACCIDENTINJURY

EMPLOYMENT RELATED









SERVICES






CITY STATE ZIP CODE


1 2 3 4 5 6 7 8

BIC Issue Date ________________

EVC _______________________


27 SURFACES



30 QUANTITY

31 PROCEDURE

NUMBER

32 FEE

33 RENDERING

PROVIDER NPI



AMOUNT

37 OTHER COVERAGE

AMOUNT

38 DATE BILLED


Address

Address 00000

X

9

X


Anytown CA 95814



80000

MM DD YY

Mary Smith MM DD YY

X



43B-PRL-TRN-006AC

6 PATIENT ADDRESS

9

MF-O


SERVICES

1

3

4

5

6

7

8

9

10

2

IMPORTANT NOTE

SIGNATURE

DATE



X






DC-217 (R 1019)


3 SEX

M F

4 PATIENT BIRTHDATE

MO DAY YR




CITY STATE

ZIP CODE

CHECK IF

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

P0 BOX 15610


Phone (800) 423-0507



HOW MANY_____________

11 CHECK IF

ACCIDENTINJURY

EMPLOYMENT RELATED

13 CHECK IF


14





16 CHDP CHECK IF

CHILD HEALTH AND


17 CCS


18 MF-O


SERVICES

10

OTHER ATTACHMENTS

12

ELIGIBILITY PENDING




CITY STATE ZIP CODE



1 2 3 4 5 6 7 8

BIC Issue Date ________________

EVC _______________________


26

TOOTHLTR

ARCHQUAD

27

SURFACES



29

DATE SERVICE

PERFORMED

30

QUANTITY

31

PROCEDURE

NUMBER

32

FEE

33

RENDERING

PROVIDER NPI

34 COMMENTS

35

TOTAL FEE

CHARGED

36 PATIENT

SHARE-OF-COST

AMOUNT

37 OTHER

COVERAGE

AMOUNT

38

DATE BILLED


Address

Address 00000

X

9

X


Anytown CA 95814





80000

MM DD YY

Mary Smith MM DD YY

X

IMPORTANT NOTICE






- TX section






image1png













44B-PRL-TRN-006AC











45B-PRL-TRN-006AC






39

X


34 COMMENTS




HOW MANY _________


41DELETE


3 SEXM F


23

16 CHDP


EMPLOYMENT RELATED

27SUR-FACES

28TOOTHNO OR

LETTERARCH

43 ADJREASON

CODE42ALLOWANCE

32FEE


31 PROCEDURENUMBER

30QTY

29 DATESERVICE

PERFORMED


35 TOTAL FEECHARGED

46 TOTALALLOWANCE


AMOUNT

38 DATEBILLED

37 OTHERCOVERAGE

AMOUNT

YES YES YES

YES

YES

YES


BIC Issue Date __________________

EVC _________________________



1

2

3

4

5

6

7

8

9

10

11

12

13

14

15





DATE

26





15550066100



YY318100124

1114YY0513YY

46B-PRL-TRN-006AC




FROM

TO

PAGE_____OF_____





39

X


34 COMMENTS

PO BOX 15609


Phone 800-423-0507


9


HOW MANY _________

10

OTHER ATTACHMENTS

41

DELETE



MO DAY YR

3 SEX

M F


23

16 CHDP


11

ACCIDENT INJURY

EMPLOYMENT RELATED

27

SUR-

FACES

28

TOOTH

NO OR

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43 ADJ

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42

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32

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33 RENDERING

PROVIDER NO

31 PROCEDURE

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30

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29 DATE

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44 DATE PROSTHESIS

ORDERED

35 TOTAL FEE

CHARGED

46 TOTAL

ALLOWANCE

36 BENEFICIARY

SHARE-OF-COST

AMOUNT

38 DATE

BILLED

37 OTHER

COVERAGE

AMOUNT

YES

YES

YES

YES

YES

YES

CHECK IF

CHECK IF

CHECK IF

CHECK IF

BIC Issue Date __________________

EVC _________________________








1

2

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1234567899 00596352



CLAIM TOTAL 13200 10100 10100


ADJUSTMENT CLAIMS


CLAIM TOTAL - 19500 - 7800 - 7800


CLAIM TOTAL 19500 16300 16300



10100 8500 18600


1

2

3

4

5

6 7

8

9 10 11 12 13

14 15 16 17 18 19 20 21 22 23 24

25 26 27

BC STA-

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OF SERVICEPROCCODE

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DOCUMENTCONTROL NO

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OTHERCOVERAGE

SHAREOF COST

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53B-PRL-TRN-006AC


DENTI-CAL



CHECK

No

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P = PAID

D = DENIED

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PLEASE CALL (800) 423-0507


BENEFICIARY NAME

MEDI-CAL

ID NO

SEX

ADJUDICATED CLAIMS

CLAIMS SPECIFIC

NON CLAIMS SPECIFIC

AMOUNT PAID

PAYABLES AMOUNT

LEVY AMOUNT

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CHECK AMOUNT




1234567899

00596352

Adams James DDS

30 Center Street

Anytown CA 95814

B LAST

FIRST

99999999D 99999999D M mmddyy

C YY163108181 D0150

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2500

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B LAST FIRST

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C YY168101357 15 D7210

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- 00

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14 D2140

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13 D2140

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CLAIM TOTAL - 19500 - 7800 - 7800

B LAST FIRST

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C YY168101357 15 D7210

0610YY P 9500 8500 8500

C

14 D2140

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13 D2140

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CLAIM TOTAL 19500 16300 16300



13200

18600 18600

10100 8500 18600


of 3

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

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26

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005963521234567899












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54B-PRL-TRN-006AC

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ID NO

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CLAIMS SPECIFIC

NON CLAIMS SPECIFIC

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00596352

1234567899

Adams James DDS

30 Center Street

Anytown CA 95814



----------------------------------------------------------------------------------------------------------------------------------------------------------------------






----------------------------------------------------------------------------------------------------------------------------------------------------------------------











+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++



FOR RESERVATIONS

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55B-PRL-TRN-006AC














56


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XSIGNATURE DATE



OPER ID ______________________________________

ACTION CODE ___________________________________

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MM DD YY

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60B-PRL-TRN-006AC








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CLAIM TOTAL -19500 - 7800 - 7800


CLAIM TOTAL 19500 16300 16300





62B-PRL-TRN-006AC



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1234567899

00596352

Adams James DDS

30 Center Street

Anytown CA 95814

10100 8500 18600

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C 14 D2140 1010YY P 5000 3900 3900

C 13 D2140 1010YY P 5000 3900 3900

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Provider Forms

Slide Number 38



Slide Number 41

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Slide Number 46




Slide Number 50


Slide Number 52

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Slide Number 54

Provider Inquiries

Slide Number 56

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Medi-Cal DentalEDI

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PROCEDURE CODE




MEMBERS OVER 21



$1800 $1350 X


$800 $600 X


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$800 $600 X



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$12000 $9000 X


$20000 $15000 X


$20000 $15000 X


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1

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4

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7

8

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DA T E

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CHECKNoPROVIDERNo

DATE PAGE NO




ADJUDICATED CLAIMS


1234567891 00596352

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CLAIM TOTAL 13200 10100 10100


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10100 8500 18600

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AM OUNTPAID

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C D1110 060113 P S019 4700 4000 4000C D1120 060113 D R019 4700 00 00


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CLAIM TAR NOA


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38 DATE

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BIC Issue Date __________________

EVC _________________________







1

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3

4

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6

7

8

9

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14

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BELOW IS


DATE

26

45 PROSTHESIS

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3 O AmalgamD2140 5500 3900 355C




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DATE

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D = DENIED

A= ADJUSTED

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NON CLAIMS SPECIFIC

1234567891

00596352

081513 1

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Adams James DDS

30 Center Street

Anytown CA 95814

CLAIM TOTAL 13200 10100 10100


ADJUSTMENT CLAIMS

10100 8500 18600

B

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BENE ID

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C D0274060113 P 3000 1800 1800

C D0230060113 P 3000 1800 1800

C D1110060113 P S019 4700 4000 4000

C D1120060113 D R019 4700 00 00



C 13168101357 15 D7210061013 A 266B - 9500 - 00 - 00

C 14 D2140061013 A - 5000 - 3900 - 3900

C 13 D2140 061013 A - 5000 - 3900 - 3900

CLAIM TOTAL -19500 - 7800 - 7800



C 13168101357 15 D7210 061013 P 9500 8500 8500

C 14 D2140 061013 P 5000 3900 3900

C 13 D2140 061013 P 5000 3900 3900

CLAIM TOTAL 19500 16300 16300





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1234567899 00596352



CLAIM TOTAL 13200 10100 10100


ADJUSTMENT CLAIMS


CLAIM TOTAL - 19500 - 7800 - 7800


CLAIM TOTAL 19500 16300 16300



10100 8500 18600


1

2

3

4

5

6 7

8

9 10 11 12 13

14 15 16 17 18 19 20 21 22 23 24

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53B-PRL-TRN-006AC


DENTI-CAL



CHECK

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D = DENIED

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BENEFICIARY NAME

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CLAIMS SPECIFIC

NON CLAIMS SPECIFIC

AMOUNT PAID

PAYABLES AMOUNT

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CHECK AMOUNT




1234567899

00596352

Adams James DDS

30 Center Street

Anytown CA 95814

B LAST

FIRST

99999999D 99999999D M mmddyy

C YY163108181 D0150

0601YY P

2500 2500

2500

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3000 1800 1800

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0610YY A 266B - 9500 - 00

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13 D2140

0610YY A - 5000 - 3900 - 3900

CLAIM TOTAL - 19500 - 7800 - 7800

B LAST FIRST

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0610YY P 9500 8500 8500

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14 D2140

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CLAIM TOTAL 19500 16300 16300



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005963521234567899












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CLAIMS SPECIFIC

NON CLAIMS SPECIFIC

AMOUNT PAID

ADJUSTMENT AMOUNT

PAYABLES AMOUNT

LEVY AMOUNT

AR AMOUNT

CHECK AMOUNT




00596352

1234567899

Adams James DDS

30 Center Street

Anytown CA 95814



----------------------------------------------------------------------------------------------------------------------------------------------------------------------






----------------------------------------------------------------------------------------------------------------------------------------------------------------------











+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++



FOR RESERVATIONS

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FOR RESERVATIONS

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55B-PRL-TRN-006AC














56


B-PRL-TRN-006AC


CLAIM INQUIRY FORM











XSIGNATURE DATE



OPER ID ______________________________________

ACTION CODE ___________________________________

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CITY STATE ZIP CODE






Anytown CA 95814

Last First

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MM DD YY

Mary Jones MM DD YY

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B-PRL-TRN-006AC


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60B-PRL-TRN-006AC








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B-PRL-TRN-006AC



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ADJUSTMENT CLAIMS


1234567899 00596352


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CLAIM TOTAL -19500 - 7800 - 7800


CLAIM TOTAL 19500 16300 16300





62B-PRL-TRN-006AC



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D = DENIED

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Adams James DDS

30 Center Street

Anytown CA 95814

10100 8500 18600

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C 13 D2140 1010YY P 5000 3900 3900

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Provider Forms

Slide Number 38



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Provider Inquiries

Slide Number 56

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Medi-Cal DentalEDI

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7B-PRL-TRN-006AC


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26B-PRL-TRN-006AC

Pregnant Members





27B-PRL-TRN-006AC


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B-PRL-TRN-006AC 28


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B-PRL-TRN-006AC 29


PROCEDURE CODE




MEMBERS OVER 21



$1800 $1350 X


$800 $600 X


1800 $1350 X


$800 $600 X



$2200 $1650 X


$12000 $9000 X


$20000 $15000 X


$20000 $15000 X


$23000 $17250 X


$23000 $17250 X


$3000 $2250 X


$3000 $2250 X


$3000 $2250 X


$3000 $2250 X


$3000 $2250 X


$3000 $2250 X


$12000 $9000 X


$1000 $750 X


$4600 $3450 X

B-PRL-TRN-006AC 30





B-PRL-TRN-006AC 31





D1310



Low risk

Moderate risk

High Risk


($1500) ($4600)

D0601 D1310 6 months $6100

D0602 D1310 4 months $6100

D0603 D1310 3 months $6100

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36B-PRL-TRN-006AC


6 PATIENT ADDRESS

9


SERVICES

1

3

4

5

6

7

8

9

10

2



SIGNATURE DATE


X



DC-217 (R0909)






CHECK IF YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES



HOW M ANY_____________

11 CHECK IF

ACCIDENTINJURY

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SERVICES





CITY STATE ZIP CODE


BIC Issue Date ________________

EVC _______________________


27 SURFACES



30 Q UANTI TY

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32 FEE

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42ALLOWANCE

32FEE


31 PROCEDURENUM BER

30QTY

29 DATESERVICE

PERFORMED


35 TOTAL FEECHARGED

46 TOTALALLOWANCE


AMOUNT

38 DATEBILLED

37 OTHERCOVERAGE

AMOUNT

YES YES YES

YES

YES

YES


BIC Issue Date __________________

EVC _________________________



1

2

3

4

5

6

7

8

9

10

11

12

13

14

15





DA T E

26





CHECKNoPROVIDERNo

DATE PAGE NO




ADJUDICATED CLAIMS


1234567891 00596352

081513 1of 3


CLAIM TOTAL 13200 10100 10100


ADJUSTMENT CLAIMS

10100 8500 18600

BC




AM OUNTPAID

OTHERCOVERAGE

SHAREOF COST

ALLOWEDAM OUNT

AM OUNTBILLED

REASONCODE

STA-TUS

DATEOF SERVICE

PROCCODE

TOOTHCODE

DOCUM ENTCONTROL NO



C D1110 060113 P S019 4700 4000 4000C D1120 060113 D R019 4700 00 00


CLAIM TOTAL -19500 - 7800 - 7800


CLAIM TOTAL 19500 16300 16300





CLAIM TAR NOA


NOTICEPAGE PAGES

OF


DOCUMENTCONTROL NO

AMOUNTBILLED




ITEMINFORMATION

BLOCKCLAIMFIELDNO

CLAIMLINE


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ERROR DESCRIPTION





PATIENT NAME



XSIGNATURE DATE



DENTI-CAL USE ONLY

DCN


CLAIMTYPE

PAGE PAGES

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CLAIMFIELD NO

CLAIMLINE

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CORRECT INFORMATION




01 01

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A

B

37B-PRL-TRN-006AC

6 PATIENT ADDRESS

9

MF-O


SERVICES

1

3

4

5

6

7

8

9

10

2

IMPORTANT NOTE

IMPORTANT NOTICE





SIGNATURE

DATE



X






DC-217 (R0909)


3 SEX

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4 PATIENT BIRTHDATE

MO DAY YR




CITY STATE

ZIP CODE

CHECK IF

YES

YES

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YES

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YES

YES

YES

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YES

YES

P0 BOX 15610


Phone (800) 423-0507



HOW MANY_____________

11 CHECK IF

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13 CHECK IF


14





16 CHDP CHECK IF

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17 CCS


18 MF-O


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10

OTHER ATTACHMENTS

12

ELIGIBILITY PENDING




CITY STATE ZIP CODE



1 2 3 4 5 6 7 8

BIC Issue Date ________________

EVC _______________________


26

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27

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29

DATE SERVICE

PERFORMED

30

QUANTITY

31

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32

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33

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34 COMMENTS

35

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36 PATIENT

SHARE-OF-COST

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37 OTHER

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38

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BOX 33 =









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29 DATE

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44 DATE PROSTHESIS

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35 TOTAL FEE

CHARGED

46 TOTAL

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36 BENEFICIARY

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AMOUNT

38 DATE

BILLED

37 OTHER

COVERAGE

AMOUNT

YES

YES

YES

YES

YES

YES

CHECK IF

CHECK IF

CHECK IF

CHECK IF

BIC Issue Date __________________

EVC _________________________







1

2

3

4

5

6

7

8

9

10

11

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13

14

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44 DATE PROSTHESIS

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35 TOTAL FEE

CHARGED

46 TOTAL

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36 BENEFICIARY

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AMOUNT

38 DATE

BILLED

37 OTHER

COVERAGE

AMOUNT

YES

YES

YES

YES

YES

YES

CHECK IF

CHECK IF

CHECK IF

CHECK IF

BIC Issue Date __________________

EVC _________________________







1

2

3

4

5

6

7

8

9

10

11

12

13

14

15







BELOW IS


DATE

26

45 PROSTHESIS

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3 O AmalgamD2140 5500 3900 355C




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44 DATE PROSTHESIS

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35 TOTAL FEECHARGED

46 TOTAL

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36 BENEFICIARY

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38 DATEBILLED






1

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B-PRL-TRN-005B

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CHECK

No

PROVIDER

No

DATE

PAGE NO


P = PAID

D = DENIED

A= ADJUSTED

PLEASE CALL (800) 423-0507


BENEFICIARY NAME

MEDI-CAL

ID NO

ADJUDICATED CLAIMS

CLAIMS SPECIFIC

NON CLAIMS SPECIFIC

1234567891

00596352

081513 1

of 3

Adams James DDS

30 Center Street

Anytown CA 95814

CLAIM TOTAL 13200 10100 10100


ADJUSTMENT CLAIMS

10100 8500 18600

B

C




BENE ID

SEX

BIRTH

DATE

AMOUNT

PAID

OTHER

COVERAGE

SHARE

OF COST

ALLOWED

AMOUNT

AMOUNT

BILLED

REASON

CODE

STA-

TUS

DATE

OF SERVICE

PROC

CODE

TOOTH

CODE

DOCUMENT

CONTROL NO

AR AMOUNT

LEVY AMOUNT

ADJUSTMENT AMOUNT

AMOUNT PAID

PAYABLES AMOUNT


C 13163108181 D0150060113 P 2500 2500 2500

C D0274060113 P 3000 1800 1800

C D0230060113 P 3000 1800 1800

C D1110060113 P S019 4700 4000 4000

C D1120060113 D R019 4700 00 00



C 13168101357 15 D7210061013 A 266B - 9500 - 00 - 00

C 14 D2140061013 A - 5000 - 3900 - 3900

C 13 D2140 061013 A - 5000 - 3900 - 3900

CLAIM TOTAL -19500 - 7800 - 7800



C 13168101357 15 D7210 061013 P 9500 8500 8500

C 14 D2140 061013 P 5000 3900 3900

C 13 D2140 061013 P 5000 3900 3900

CLAIM TOTAL 19500 16300 16300





1 Provider info

2 Check






PO BOX 15609


Phone 800-423-0507


CLAIM

TAR

NOA






NOTICE

PAGE PAGES

OF

RTD ISSUE DATE

RTD DUE DATE

DOCUMENT

CONTROL NO

AMOUNT

BILLED

BEGINNING

DATE OF SERVICE

PATIENT DENTAL

RECORD NO

PATIENT MEDI-CAL

ID NUMBER

PATIENT NAME

ITEM

INFORMATION

BLOCK

CLAIM

FIELD

NO

CLAIM

LINE

SUBMITTED

INFORMATION

ERROR

CODE

ERROR DESCRIPTION

RETAIN THIS PORTION





PATIENT NAME






X

SIGNATURE

DATE





DENTI-CAL USE ONLY

DCN


CLAIM

TYPE

PAGE

PAGES

OF

CLAIM

FIELD NO

CLAIM

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ERROR

CODE




CORRECT INFORMATION



MAILING ADDRESS

CITY STATE ZIP CODE


01 01

PROCEDURE

CODE

A

B

10






image1png

































38B-PRL-TRN-006AC






39B-PRL-TRN-006AC












40B-PRL-TRN-006AC

6 PATIENT ADDRESS

9


SERVICES

1

3

4

5

6

7

8

9

10

2


SIGNATURE DATE


X



DC-217 (R 1019)






CHECK IF YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES



HOW MANY_____________

11 CHECK IF

ACCIDENTINJURY

EMPLOYMENT RELATED









SERVICES






CITY STATE ZIP CODE


1 2 3 4 5 6 7 8

BIC Issue Date ________________

EVC _______________________


27 SURFACES



30 QUANTITY

31 PROCEDURE

NUMBER

32 FEE

33 RENDERING

PROVIDER NPI



AMOUNT

37 OTHER COVERAGE

AMOUNT

38 DATE BILLED


Address

Address 00000

40900

MM DD YY

X

3

X






ANYTOWN CA 95814

mmddyy

123456789A1

41B-PRL-TRN-006AC

6 PATIENT ADDRESS

9

MF-O


SERVICES

1

3

4

5

6

7

8

9

10

2

IMPORTANT NOTICE



SIGNATURE

DATE



X






DC-217 (R 1019)


3 SEX

M F

4 PATIENT BIRTHDATE

MO DAY YR




CITY STATE

ZIP CODE

CHECK IF

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

P0 BOX 15610


Phone (800) 423-0507



HOW MANY_____________

11 CHECK IF

ACCIDENTINJURY

EMPLOYMENT RELATED

13 CHECK IF


14





16 CHDP CHECK IF

CHILD HEALTH AND


17 CCS


18 MF-O


SERVICES

10

OTHER ATTACHMENTS

12

ELIGIBILITY PENDING




CITY STATE ZIP CODE



1 2 3 4 5 6 7 8

BIC Issue Date ________________

EVC _______________________


26

TOOTHLTR

ARCHQUAD

27

SURFACES



29

DATE SERVICE

PERFORMED

30

QUANTITY

31

PROCEDURE

NUMBER

32

FEE

33

RENDERING

PROVIDER NPI

34 COMMENTS

35

TOTAL FEE

CHARGED

36 PATIENT

SHARE-OF-COST

AMOUNT

37 OTHER

COVERAGE

AMOUNT

38

DATE BILLED


Address

Address 00000

40900

MM DD YY

X

3

X

Exam MM DD YY D0150 2500 9912345678








ANYTOWN CA 95814




3= sex

4= Bdate= modayyr

















TX Section




BOX 33 =






BILLING LIMITATIONS



image1png





3SEXM F






6PATIENT ADDRESS

CITY STATE

9 YESCHECK IF


HOW MANY_____________

YES

11ACCIDENTINJURY

EMPLOYMENT RELATED

CHECK IF YES

YES

YES





YES

YES

YES

16

17

18





SERVICES

YES

YES

YES





HOSPITALIN-PATIENT




28 32FEE

33RENDERING

PROVIDER NPI

CHECK IF CHECK IF

1

3

4

5

6

7

8

9

10

2


36

37

38 DATEBILLED


SIGNATURE DATE


X



SERVICES



10

OTHER ATTACHMENTS


EVC 123456789A1

1 2 3 4 5 6 7 8


27SURFACES

30QUANTITY

31PROCEDURE

NUMBER



AMOUNT

35


OTHER COVERAGE

AMOUNT


Address

Address 00000



ANYTOWN CA 95814

Mary Smith MM DD YY

Prophy MM DD YY D1110 8500 9912345678

8500

MM DD YY

DC-217 (R 1019)

1

1 2

3

4

42B-PRL-TRN-006AC

PO BOX 15610


Phone 800-423-0507


3SEX

M F

4PATIENT BIRTHDATE

MO DAY YR



ZIP CODE



6PATIENT ADDRESS

CITY STATE

9

YES

CHECK IF


HOW MANY_____________

YES

11

ACCIDENTINJURY

EMPLOYMENT RELATED

CHECK IF

YES

YES

YES

13


14





YES

YES

YES

16

17

18

CHDP

CHILD HEALTH AND


ccs


MF-O


SERVICES

YES

YES

YES



21 MAILING ADDRESS

TELEPHONE NUMBER

( )

CITY STATE

ZIP CODE

22 PLACE OF SERVICE


HOSPITAL

IN-PATIENT

HOSPITAL

OUT-PATIENT

OTHER

(PLEASE SPECIFY)


26

TOOTHLTR

ARCHQUAD

28

32

FEE

33

RENDERING

PROVIDER NPI

CHECK IF

CHECK IF

1

3

4

5

6

7

8

9

10

2

34 COMMENTS

TOTAL FEE

CHARGED

36

37

38

DATE

BILLED

IMPORTANT NOTE

IMPORTANT NOTICE



SIGNATURE

DATE



X


MF-O


SERVICES

12

ELIGIBILITY PENDING


10

OTHER ATTACHMENTS


EVC 123456789A1

1 2 3 4 5 6 7 8



27

SURFACES

30

QUANTITY

31

PROCEDURE

NUMBER

29

DATE SERVICE

PERFORMED

PATIENT

SHARE- OF- COST

AMOUNT

35





OTHER

COVERAGE

AMOUNT


Address

Address 00000



ANYTOWN CA 95814

Mary Smith MM DD YY

Prophy MM DD YY D1110 8500 9912345678

8500

MM DD YY

DC-217 (R 1019)

image1png

6 PATIENT ADDRESS

9


SERVICES

1

3

4

5

6

7

8

9

10

2

IMPORTANT NOTE

SIGNATURE DATE


X



DC-217 (R 1019)






CHECK IF YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES



HOW MANY_____________

11 CHECK IF

ACCIDENTINJURY

EMPLOYMENT RELATED









SERVICES






CITY STATE ZIP CODE


1 2 3 4 5 6 7 8

BIC Issue Date ________________

EVC _______________________


27 SURFACES



30 QUANTITY

31 PROCEDURE

NUMBER

32 FEE

33 RENDERING

PROVIDER NPI



AMOUNT

37 OTHER COVERAGE

AMOUNT

38 DATE BILLED


Address

Address 00000

X

9

X


Anytown CA 95814



80000

MM DD YY

Mary Smith MM DD YY

X



43B-PRL-TRN-006AC

6 PATIENT ADDRESS

9

MF-O


SERVICES

1

3

4

5

6

7

8

9

10

2

IMPORTANT NOTE

SIGNATURE

DATE



X






DC-217 (R 1019)


3 SEX

M F

4 PATIENT BIRTHDATE

MO DAY YR




CITY STATE

ZIP CODE

CHECK IF

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

P0 BOX 15610


Phone (800) 423-0507



HOW MANY_____________

11 CHECK IF

ACCIDENTINJURY

EMPLOYMENT RELATED

13 CHECK IF


14





16 CHDP CHECK IF

CHILD HEALTH AND


17 CCS


18 MF-O


SERVICES

10

OTHER ATTACHMENTS

12

ELIGIBILITY PENDING




CITY STATE ZIP CODE



1 2 3 4 5 6 7 8

BIC Issue Date ________________

EVC _______________________


26

TOOTHLTR

ARCHQUAD

27

SURFACES



29

DATE SERVICE

PERFORMED

30

QUANTITY

31

PROCEDURE

NUMBER

32

FEE

33

RENDERING

PROVIDER NPI

34 COMMENTS

35

TOTAL FEE

CHARGED

36 PATIENT

SHARE-OF-COST

AMOUNT

37 OTHER

COVERAGE

AMOUNT

38

DATE BILLED


Address

Address 00000

X

9

X


Anytown CA 95814





80000

MM DD YY

Mary Smith MM DD YY

X

IMPORTANT NOTICE






- TX section






image1png













44B-PRL-TRN-006AC











45B-PRL-TRN-006AC






39

X


34 COMMENTS




HOW MANY _________


41DELETE


3 SEXM F


23

16 CHDP


EMPLOYMENT RELATED

27SUR-FACES

28TOOTHNO OR

LETTERARCH

43 ADJREASON

CODE42ALLOWANCE

32FEE


31 PROCEDURENUMBER

30QTY

29 DATESERVICE

PERFORMED


35 TOTAL FEECHARGED

46 TOTALALLOWANCE


AMOUNT

38 DATEBILLED

37 OTHERCOVERAGE

AMOUNT

YES YES YES

YES

YES

YES


BIC Issue Date __________________

EVC _________________________



1

2

3

4

5

6

7

8

9

10

11

12

13

14

15





DATE

26





15550066100



YY318100124

1114YY0513YY

46B-PRL-TRN-006AC




FROM

TO

PAGE_____OF_____





39

X


34 COMMENTS

PO BOX 15609


Phone 800-423-0507


9


HOW MANY _________

10

OTHER ATTACHMENTS

41

DELETE



MO DAY YR

3 SEX

M F


23

16 CHDP


11

ACCIDENT INJURY

EMPLOYMENT RELATED

27

SUR-

FACES

28

TOOTH

NO OR

LETTER

ARCH

43 ADJ

REASON

CODE

42

ALLOWANCE

32

FEE

33 RENDERING

PROVIDER NO

31 PROCEDURE

NUMBER

30

QTY

29 DATE

SERVICE

PERFORMED

44 DATE PROSTHESIS

ORDERED

35 TOTAL FEE

CHARGED

46 TOTAL

ALLOWANCE

36 BENEFICIARY

SHARE-OF-COST

AMOUNT

38 DATE

BILLED

37 OTHER

COVERAGE

AMOUNT

YES

YES

YES

YES

YES

YES

CHECK IF

CHECK IF

CHECK IF

CHECK IF

BIC Issue Date __________________

EVC _________________________








1

2

3

4

5

6

7

8

9

10

11

12

13

14

15







BELOW IS


DATE

26

45 PROSTHESIS

LINE ITEM




3 O AmalgamD2140 5500 3900 355C




155500

66100



Anytown CA 95814


YY318100124

1114YY

0513YY



2 DCN










Box 33=





image1png









47B-PRL-TRN-006AC








EXAMPLE OF NOA


48B-PRL-TRN-006AC








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49B-PRL-TRN-006AC

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52


B-PRL-TRN-006AC



CHECKNoPROVIDER

No




ADJUDICATED CLAIMS





1234567899 00596352



CLAIM TOTAL 13200 10100 10100


ADJUSTMENT CLAIMS


CLAIM TOTAL - 19500 - 7800 - 7800


CLAIM TOTAL 19500 16300 16300



10100 8500 18600


1

2

3

4

5

6 7

8

9 10 11 12 13

14 15 16 17 18 19 20 21 22 23 24

25 26 27

BC STA-

TUSDATE

OF SERVICEPROCCODE

TOOTHCODE

DOCUMENTCONTROL NO

AMOUNTPAID

OTHERCOVERAGE

SHAREOF COST

ALLOWEDAMOUNT

AMOUNTBILLED

REASONCODE

BENE ID BIRTHDATE

ADJUSTMENT AMOUNT

53B-PRL-TRN-006AC


DENTI-CAL



CHECK

No

PROVIDER

No


P = PAID

D = DENIED

A= ADJUSTED

PLEASE CALL (800) 423-0507


BENEFICIARY NAME

MEDI-CAL

ID NO

SEX

ADJUDICATED CLAIMS

CLAIMS SPECIFIC

NON CLAIMS SPECIFIC

AMOUNT PAID

PAYABLES AMOUNT

LEVY AMOUNT

AR AMOUNT

CHECK AMOUNT




1234567899

00596352

Adams James DDS

30 Center Street

Anytown CA 95814

B LAST

FIRST

99999999D 99999999D M mmddyy

C YY163108181 D0150

0601YY P

2500 2500

2500

C

D0274

0601YY P

3000 1800 1800

C

D0230

0601YY P

3000 1800

1800

C

D1120

0601YY

D R019

4700

00 00

C D1110

0601YY P S019

4700 4000

4000

CLAIM TOTAL

13200

10100

10100


13200 10100

10100

ADJUSTMENT CLAIMS

B LAST FIRST

99999999D 99999999D F mmddyy


C YY168101357 15 D7210

0610YY A 266B - 9500 - 00

- 00

C

14 D2140

0610YY A - 5000 - 3900 - 3900

C

13 D2140

0610YY A - 5000 - 3900 - 3900

CLAIM TOTAL - 19500 - 7800 - 7800

B LAST FIRST

99999999D 99999999D F mmddyy


C YY168101357 15 D7210

0610YY P 9500 8500 8500

C

14 D2140

0610YY P 5000 3900 3900

C

13 D2140

0610YY P 5000 3900 3900

CLAIM TOTAL 19500 16300 16300



13200

18600 18600

10100 8500 18600


of 3

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

B

C

STA-

TUS

DATE

OF SERVICE

PROC

CODE

TOOTH

CODE

DOCUMENT

CONTROL NO

AMOUNT

PAID

OTHER

COVERAGE

SHARE

OF COST

ALLOWED

AMOUNT

AMOUNT

BILLED

REASON

CODE

BENE ID

BIRTH

DATE

ADJUSTMENT AMOUNT



CHECKNoPROVIDER

No






AMOUNTPAID

ALLOWEDAMOUNT




005963521234567899












BC DOCUMENT

CONTROL NOOTHER

COVERAGESHARE

OF COSTAMOUNTBILLED

REASONCODE

STA-TUS

DATEOF SERVICE

PROCCODE

TOOTHCODE

54B-PRL-TRN-006AC

OTHER

COVERAGE

SHARE

OF COST

AMOUNT

BILLED

REASON

CODE

STA-

TUS

DATE

OF SERVICE

PROC

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DENTI-CAL



CHECK

No

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No


of 3


P = PAID

D = DENIED

A= ADJUSTED

PLEASE CALL (800) 423-0507


BENEFICIARY NAME

MEDI-CAL

ID NO

BENE ID

SEX

BIRTH

DATE

AMOUNT

PAID

ALLOWED

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CLAIMS SPECIFIC

NON CLAIMS SPECIFIC

AMOUNT PAID

ADJUSTMENT AMOUNT

PAYABLES AMOUNT

LEVY AMOUNT

AR AMOUNT

CHECK AMOUNT




00596352

1234567899

Adams James DDS

30 Center Street

Anytown CA 95814



----------------------------------------------------------------------------------------------------------------------------------------------------------------------






----------------------------------------------------------------------------------------------------------------------------------------------------------------------











+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++



FOR RESERVATIONS

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++



FOR RESERVATIONS

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++



FOR RESERVATIONS

B

C

DOCUMENT

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UNKNOWN-0


55B-PRL-TRN-006AC














56


B-PRL-TRN-006AC


CLAIM INQUIRY FORM











XSIGNATURE DATE



OPER ID ______________________________________

ACTION CODE ___________________________________

IMPORTANT


DATE BILLED

CITY STATE ZIP CODE






Anytown CA 95814

Last First

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MM DD YY

Mary Jones MM DD YY

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B-PRL-TRN-006AC


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PO BOX 15609


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X

SIGNATURE DATE




OPER ID ______________________________________

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Last First

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58


B-PRL-TRN-006AC


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XSIGNATURE DATE



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Mary Jones mm dd yy

59B-PRL-TRN-006AC


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PO BOX 15609


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X

SIGNATURE DATE




OPER ID ______________________________________

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image1png


First Level Appeals

60B-PRL-TRN-006AC








61


B-PRL-TRN-006AC



CHECKNoPROVIDERNo





BIRTHDATE

ADJUSTMENT CLAIMS


1234567899 00596352


10100 8500 18600

CB



BENE ID

DOCUMENTCONTROL NO

TOOTHCODE

PROCCODE

DATEOF SERVICE

STA-TUS

REASONCODE

AMOUNTBILLED

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SHAREOF COST

OTHERCOVERAGE

AMOUNTPAID




CLAIM TOTAL -19500 - 7800 - 7800


CLAIM TOTAL 19500 16300 16300





62B-PRL-TRN-006AC



CHECK

No

PROVIDER

No


of 3


P = PAID

D = DENIED

A= ADJUSTED

PLEASE CALL (800) 423-0507


BENEFICIARY NAME

MEDI-CAL

ID NO

SEX

BIRTH

DATE

ADJUSTMENT CLAIMS

CLAIMS SPECIFIC

NON CLAIMS SPECIFIC

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1234567899

00596352

Adams James DDS

30 Center Street

Anytown CA 95814

10100 8500 18600

C

B




BENE ID

DOCUMENT

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TOOTH

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PROC

CODE

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C YY168101357 15 D7210 1010YY A 266B - 9500 - 00 - 00

C 14 D2140 1010YY A - 5000 - 3900 - 3900

C 13 D2140 1010YY A - 5000 - 3900 - 3900

CLAIM TOTAL -19500 - 7800 - 7800



C YY168101357 15 D7210 1010YY P 9500 8500 8500

C 14 D2140 1010YY P 5000 3900 3900

C 13 D2140 1010YY P 5000 3900 3900

CLAIM TOTAL 19500 16300 16300



----------------------------------------------------------------------------------------------------------------------------------







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Provider Forms

Slide Number 38



Slide Number 41

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Slide Number 46




Slide Number 50


Slide Number 52

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Slide Number 54

Provider Inquiries

Slide Number 56

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Medi-Cal DentalEDI

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B-PRL-TRN-006AC 28


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PROCEDURE CODE




MEMBERS OVER 21



$1800 $1350 X


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$12000 $9000 X


$20000 $15000 X


$20000 $15000 X


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$3000 $2250 X


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B-PRL-TRN-006AC 30





B-PRL-TRN-006AC 31





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4

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1

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4

5

6

7

8

9

10

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12

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14

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DA T E

26





CHECKNoPROVIDERNo

DATE PAGE NO




ADJUDICATED CLAIMS


1234567891 00596352

081513 1of 3


CLAIM TOTAL 13200 10100 10100


ADJUSTMENT CLAIMS

10100 8500 18600

BC




AM OUNTPAID

OTHERCOVERAGE

SHAREOF COST

ALLOWEDAM OUNT

AM OUNTBILLED

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C D1110 060113 P S019 4700 4000 4000C D1120 060113 D R019 4700 00 00


CLAIM TOTAL -19500 - 7800 - 7800


CLAIM TOTAL 19500 16300 16300





CLAIM TAR NOA


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BIC Issue Date __________________

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BIC Issue Date __________________

EVC _________________________







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No

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No

DATE

PAGE NO


P = PAID

D = DENIED

A= ADJUSTED

PLEASE CALL (800) 423-0507


BENEFICIARY NAME

MEDI-CAL

ID NO

ADJUDICATED CLAIMS

CLAIMS SPECIFIC

NON CLAIMS SPECIFIC

1234567891

00596352

081513 1

of 3

Adams James DDS

30 Center Street

Anytown CA 95814

CLAIM TOTAL 13200 10100 10100


ADJUSTMENT CLAIMS

10100 8500 18600

B

C




BENE ID

SEX

BIRTH

DATE

AMOUNT

PAID

OTHER

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SHARE

OF COST

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STA-

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DATE

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PROC

CODE

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CONTROL NO

AR AMOUNT

LEVY AMOUNT

ADJUSTMENT AMOUNT

AMOUNT PAID

PAYABLES AMOUNT


C 13163108181 D0150060113 P 2500 2500 2500

C D0274060113 P 3000 1800 1800

C D0230060113 P 3000 1800 1800

C D1110060113 P S019 4700 4000 4000

C D1120060113 D R019 4700 00 00



C 13168101357 15 D7210061013 A 266B - 9500 - 00 - 00

C 14 D2140061013 A - 5000 - 3900 - 3900

C 13 D2140 061013 A - 5000 - 3900 - 3900

CLAIM TOTAL -19500 - 7800 - 7800



C 13168101357 15 D7210 061013 P 9500 8500 8500

C 14 D2140 061013 P 5000 3900 3900

C 13 D2140 061013 P 5000 3900 3900

CLAIM TOTAL 19500 16300 16300





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1234567899 00596352



CLAIM TOTAL 13200 10100 10100


ADJUSTMENT CLAIMS


CLAIM TOTAL - 19500 - 7800 - 7800


CLAIM TOTAL 19500 16300 16300



10100 8500 18600


1

2

3

4

5

6 7

8

9 10 11 12 13

14 15 16 17 18 19 20 21 22 23 24

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53B-PRL-TRN-006AC


DENTI-CAL



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1234567899

00596352

Adams James DDS

30 Center Street

Anytown CA 95814

B LAST

FIRST

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CLAIM TOTAL

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B LAST FIRST

99999999D 99999999D F mmddyy


C YY168101357 15 D7210

0610YY A 266B - 9500 - 00

- 00

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C

13 D2140

0610YY A - 5000 - 3900 - 3900

CLAIM TOTAL - 19500 - 7800 - 7800

B LAST FIRST

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0610YY P 9500 8500 8500

C

14 D2140

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C

13 D2140

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CLAIM TOTAL 19500 16300 16300



13200

18600 18600

10100 8500 18600


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00596352

1234567899

Adams James DDS

30 Center Street

Anytown CA 95814



----------------------------------------------------------------------------------------------------------------------------------------------------------------------






----------------------------------------------------------------------------------------------------------------------------------------------------------------------











+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++



FOR RESERVATIONS

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FOR RESERVATIONS

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55B-PRL-TRN-006AC














56


B-PRL-TRN-006AC


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XSIGNATURE DATE



OPER ID ______________________________________

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Anytown CA 95814

Last First

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MM DD YY

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B-PRL-TRN-006AC


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60B-PRL-TRN-006AC








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CLAIM TOTAL -19500 - 7800 - 7800


CLAIM TOTAL 19500 16300 16300





62B-PRL-TRN-006AC



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Adams James DDS

30 Center Street

Anytown CA 95814

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C 14 D2140 1010YY A - 5000 - 3900 - 3900

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CLAIM TOTAL -19500 - 7800 - 7800



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C 14 D2140 1010YY P 5000 3900 3900

C 13 D2140 1010YY P 5000 3900 3900

CLAIM TOTAL 19500 16300 16300



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9B-PRL-TRN-006AC




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25B-PRL-TRN-006AC



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26B-PRL-TRN-006AC

Pregnant Members





27B-PRL-TRN-006AC


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B-PRL-TRN-006AC 28


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B-PRL-TRN-006AC 29


PROCEDURE CODE




MEMBERS OVER 21



$1800 $1350 X


$800 $600 X


1800 $1350 X


$800 $600 X



$2200 $1650 X


$12000 $9000 X


$20000 $15000 X


$20000 $15000 X


$23000 $17250 X


$23000 $17250 X


$3000 $2250 X


$3000 $2250 X


$3000 $2250 X


$3000 $2250 X


$3000 $2250 X


$3000 $2250 X


$12000 $9000 X


$1000 $750 X


$4600 $3450 X

B-PRL-TRN-006AC 30





B-PRL-TRN-006AC 31





D1310



Low risk

Moderate risk

High Risk


($1500) ($4600)

D0601 D1310 6 months $6100

D0602 D1310 4 months $6100

D0603 D1310 3 months $6100

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Senate Bill 639






36B-PRL-TRN-006AC


6 PATIENT ADDRESS

9


SERVICES

1

3

4

5

6

7

8

9

10

2



SIGNATURE DATE


X



DC-217 (R0909)






CHECK IF YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES



HOW M ANY_____________

11 CHECK IF

ACCIDENTINJURY

EM PLOYMENT RELATED









SERVICES





CITY STATE ZIP CODE


BIC Issue Date ________________

EVC _______________________


27 SURFACES



30 Q UANTI TY

31 PROCEDURE

NUMBER

32 FEE

33 RENDERING

PROVIDER NO


CHARG ED


AM O UNT


AM O UNT

38 DATE BI LLED

wwwdenti -ca lcagov






39

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34 COMMENTS




HOW M ANY _________


41DELETE


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EMPLOYMENT RELATED

27SUR-FACES

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43 ADJREASONCODE

42ALLOWANCE

32FEE


31 PROCEDURENUM BER

30QTY

29 DATESERVICE

PERFORMED


35 TOTAL FEECHARGED

46 TOTALALLOWANCE


AMOUNT

38 DATEBILLED

37 OTHERCOVERAGE

AMOUNT

YES YES YES

YES

YES

YES


BIC Issue Date __________________

EVC _________________________



1

2

3

4

5

6

7

8

9

10

11

12

13

14

15





DA T E

26





CHECKNoPROVIDERNo

DATE PAGE NO




ADJUDICATED CLAIMS


1234567891 00596352

081513 1of 3


CLAIM TOTAL 13200 10100 10100


ADJUSTMENT CLAIMS

10100 8500 18600

BC




AM OUNTPAID

OTHERCOVERAGE

SHAREOF COST

ALLOWEDAM OUNT

AM OUNTBILLED

REASONCODE

STA-TUS

DATEOF SERVICE

PROCCODE

TOOTHCODE

DOCUM ENTCONTROL NO



C D1110 060113 P S019 4700 4000 4000C D1120 060113 D R019 4700 00 00


CLAIM TOTAL -19500 - 7800 - 7800


CLAIM TOTAL 19500 16300 16300





CLAIM TAR NOA


NOTICEPAGE PAGES

OF


DOCUMENTCONTROL NO

AMOUNTBILLED




ITEMINFORMATION

BLOCKCLAIMFIELDNO

CLAIMLINE


ERRORCODE

ERROR DESCRIPTION





PATIENT NAME



XSIGNATURE DATE



DENTI-CAL USE ONLY

DCN


CLAIMTYPE

PAGE PAGES

OF

CLAIMFIELD NO

CLAIMLINE

ERRORCODE


CORRECT INFORMATION




01 01

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A

B

37B-PRL-TRN-006AC

6 PATIENT ADDRESS

9

MF-O


SERVICES

1

3

4

5

6

7

8

9

10

2

IMPORTANT NOTE

IMPORTANT NOTICE





SIGNATURE

DATE



X






DC-217 (R0909)


3 SEX

M F

4 PATIENT BIRTHDATE

MO DAY YR




CITY STATE

ZIP CODE

CHECK IF

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

P0 BOX 15610


Phone (800) 423-0507



HOW MANY_____________

11 CHECK IF

ACCIDENTINJURY

EMPLOYMENT RELATED

13 CHECK IF


14





16 CHDP CHECK IF

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17 CCS


18 MF-O


SERVICES

10

OTHER ATTACHMENTS

12

ELIGIBILITY PENDING




CITY STATE ZIP CODE



1 2 3 4 5 6 7 8

BIC Issue Date ________________

EVC _______________________


26

TOOTHLTR

ARCHQUAD

27

SURFACES



29

DATE SERVICE

PERFORMED

30

QUANTITY

31

PROCEDURE

NUMBER

32

FEE

33

RENDERING

PROVIDER NO

34 COMMENTS

35

TOTAL FEE

CHARGED

36 PATIENT

SHARE-OF-COST

AMOUNT

37 OTHER

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38

DATE BILLED

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3= sex

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BOX 33 =









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31 PROCEDURE

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29 DATE

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44 DATE PROSTHESIS

ORDERED

35 TOTAL FEE

CHARGED

46 TOTAL

ALLOWANCE

36 BENEFICIARY

SHARE-OF-COST

AMOUNT

38 DATE

BILLED

37 OTHER

COVERAGE

AMOUNT

YES

YES

YES

YES

YES

YES

CHECK IF

CHECK IF

CHECK IF

CHECK IF

BIC Issue Date __________________

EVC _________________________







1

2

3

4

5

6

7

8

9

10

11

12

13

14

15







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26

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41

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33 RENDERING

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31 PROCEDURE

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30

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29 DATE

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44 DATE PROSTHESIS

ORDERED

35 TOTAL FEE

CHARGED

46 TOTAL

ALLOWANCE

36 BENEFICIARY

SHARE-OF-COST

AMOUNT

38 DATE

BILLED

37 OTHER

COVERAGE

AMOUNT

YES

YES

YES

YES

YES

YES

CHECK IF

CHECK IF

CHECK IF

CHECK IF

BIC Issue Date __________________

EVC _________________________







1

2

3

4

5

6

7

8

9

10

11

12

13

14

15







BELOW IS


DATE

26

45 PROSTHESIS

LINE ITEM




3 O AmalgamD2140 5500 3900 355C




155500

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Anytown CA 95814


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31

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34 COMMENTS

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HOW MANY _________


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27

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33 RENDERING


NUMBER

30QTY


44 DATE PROSTHESIS

ORDERED

35 TOTAL FEECHARGED

46 TOTAL

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36 BENEFICIARY

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AMOUNT

38 DATEBILLED






1

23

4

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67

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DATE

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155500

66100



Anytown CA95814


10318100124

111410051311

31

B-PRL-TRN-005B

image1png


DENTI-CAL



CHECK

No

PROVIDER

No

DATE

PAGE NO


P = PAID

D = DENIED

A= ADJUSTED

PLEASE CALL (800) 423-0507


BENEFICIARY NAME

MEDI-CAL

ID NO

ADJUDICATED CLAIMS

CLAIMS SPECIFIC

NON CLAIMS SPECIFIC

1234567891

00596352

081513 1

of 3

Adams James DDS

30 Center Street

Anytown CA 95814

CLAIM TOTAL 13200 10100 10100


ADJUSTMENT CLAIMS

10100 8500 18600

B

C




BENE ID

SEX

BIRTH

DATE

AMOUNT

PAID

OTHER

COVERAGE

SHARE

OF COST

ALLOWED

AMOUNT

AMOUNT

BILLED

REASON

CODE

STA-

TUS

DATE

OF SERVICE

PROC

CODE

TOOTH

CODE

DOCUMENT

CONTROL NO

AR AMOUNT

LEVY AMOUNT

ADJUSTMENT AMOUNT

AMOUNT PAID

PAYABLES AMOUNT


C 13163108181 D0150060113 P 2500 2500 2500

C D0274060113 P 3000 1800 1800

C D0230060113 P 3000 1800 1800

C D1110060113 P S019 4700 4000 4000

C D1120060113 D R019 4700 00 00



C 13168101357 15 D7210061013 A 266B - 9500 - 00 - 00

C 14 D2140061013 A - 5000 - 3900 - 3900

C 13 D2140 061013 A - 5000 - 3900 - 3900

CLAIM TOTAL -19500 - 7800 - 7800



C 13168101357 15 D7210 061013 P 9500 8500 8500

C 14 D2140 061013 P 5000 3900 3900

C 13 D2140 061013 P 5000 3900 3900

CLAIM TOTAL 19500 16300 16300





1 Provider info

2 Check






PO BOX 15609


Phone 800-423-0507


CLAIM

TAR

NOA






NOTICE

PAGE PAGES

OF

RTD ISSUE DATE

RTD DUE DATE

DOCUMENT

CONTROL NO

AMOUNT

BILLED

BEGINNING

DATE OF SERVICE

PATIENT DENTAL

RECORD NO

PATIENT MEDI-CAL

ID NUMBER

PATIENT NAME

ITEM

INFORMATION

BLOCK

CLAIM

FIELD

NO

CLAIM

LINE

SUBMITTED

INFORMATION

ERROR

CODE

ERROR DESCRIPTION

RETAIN THIS PORTION





PATIENT NAME






X

SIGNATURE

DATE





DENTI-CAL USE ONLY

DCN


CLAIM

TYPE

PAGE

PAGES

OF

CLAIM

FIELD NO

CLAIM

LINE

ERROR

CODE




CORRECT INFORMATION



MAILING ADDRESS

CITY STATE ZIP CODE


01 01

PROCEDURE

CODE

A

B

10






image1png

































38B-PRL-TRN-006AC






39B-PRL-TRN-006AC












40B-PRL-TRN-006AC

6 PATIENT ADDRESS

9


SERVICES

1

3

4

5

6

7

8

9

10

2


SIGNATURE DATE


X



DC-217 (R 1019)






CHECK IF YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES



HOW MANY_____________

11 CHECK IF

ACCIDENTINJURY

EMPLOYMENT RELATED









SERVICES






CITY STATE ZIP CODE


1 2 3 4 5 6 7 8

BIC Issue Date ________________

EVC _______________________


27 SURFACES



30 QUANTITY

31 PROCEDURE

NUMBER

32 FEE

33 RENDERING

PROVIDER NPI



AMOUNT

37 OTHER COVERAGE

AMOUNT

38 DATE BILLED


Address

Address 00000

40900

MM DD YY

X

3

X






ANYTOWN CA 95814

mmddyy

123456789A1

41B-PRL-TRN-006AC

6 PATIENT ADDRESS

9

MF-O


SERVICES

1

3

4

5

6

7

8

9

10

2

IMPORTANT NOTICE



SIGNATURE

DATE



X






DC-217 (R 1019)


3 SEX

M F

4 PATIENT BIRTHDATE

MO DAY YR




CITY STATE

ZIP CODE

CHECK IF

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

P0 BOX 15610


Phone (800) 423-0507



HOW MANY_____________

11 CHECK IF

ACCIDENTINJURY

EMPLOYMENT RELATED

13 CHECK IF


14





16 CHDP CHECK IF

CHILD HEALTH AND


17 CCS


18 MF-O


SERVICES

10

OTHER ATTACHMENTS

12

ELIGIBILITY PENDING




CITY STATE ZIP CODE



1 2 3 4 5 6 7 8

BIC Issue Date ________________

EVC _______________________


26

TOOTHLTR

ARCHQUAD

27

SURFACES



29

DATE SERVICE

PERFORMED

30

QUANTITY

31

PROCEDURE

NUMBER

32

FEE

33

RENDERING

PROVIDER NPI

34 COMMENTS

35

TOTAL FEE

CHARGED

36 PATIENT

SHARE-OF-COST

AMOUNT

37 OTHER

COVERAGE

AMOUNT

38

DATE BILLED


Address

Address 00000

40900

MM DD YY

X

3

X

Exam MM DD YY D0150 2500 9912345678








ANYTOWN CA 95814




3= sex

4= Bdate= modayyr

















TX Section




BOX 33 =






BILLING LIMITATIONS



image1png





3SEXM F






6PATIENT ADDRESS

CITY STATE

9 YESCHECK IF


HOW MANY_____________

YES

11ACCIDENTINJURY

EMPLOYMENT RELATED

CHECK IF YES

YES

YES





YES

YES

YES

16

17

18





SERVICES

YES

YES

YES





HOSPITALIN-PATIENT




28 32FEE

33RENDERING

PROVIDER NPI

CHECK IF CHECK IF

1

3

4

5

6

7

8

9

10

2


36

37

38 DATEBILLED


SIGNATURE DATE


X



SERVICES



10

OTHER ATTACHMENTS


EVC 123456789A1

1 2 3 4 5 6 7 8


27SURFACES

30QUANTITY

31PROCEDURE

NUMBER



AMOUNT

35


OTHER COVERAGE

AMOUNT


Address

Address 00000



ANYTOWN CA 95814

Mary Smith MM DD YY

Prophy MM DD YY D1110 8500 9912345678

8500

MM DD YY

DC-217 (R 1019)

1

1 2

3

4

42B-PRL-TRN-006AC

PO BOX 15610


Phone 800-423-0507


3SEX

M F

4PATIENT BIRTHDATE

MO DAY YR



ZIP CODE



6PATIENT ADDRESS

CITY STATE

9

YES

CHECK IF


HOW MANY_____________

YES

11

ACCIDENTINJURY

EMPLOYMENT RELATED

CHECK IF

YES

YES

YES

13


14





YES

YES

YES

16

17

18

CHDP

CHILD HEALTH AND


ccs


MF-O


SERVICES

YES

YES

YES



21 MAILING ADDRESS

TELEPHONE NUMBER

( )

CITY STATE

ZIP CODE

22 PLACE OF SERVICE


HOSPITAL

IN-PATIENT

HOSPITAL

OUT-PATIENT

OTHER

(PLEASE SPECIFY)


26

TOOTHLTR

ARCHQUAD

28

32

FEE

33

RENDERING

PROVIDER NPI

CHECK IF

CHECK IF

1

3

4

5

6

7

8

9

10

2

34 COMMENTS

TOTAL FEE

CHARGED

36

37

38

DATE

BILLED

IMPORTANT NOTE

IMPORTANT NOTICE



SIGNATURE

DATE



X


MF-O


SERVICES

12

ELIGIBILITY PENDING


10

OTHER ATTACHMENTS


EVC 123456789A1

1 2 3 4 5 6 7 8



27

SURFACES

30

QUANTITY

31

PROCEDURE

NUMBER

29

DATE SERVICE

PERFORMED

PATIENT

SHARE- OF- COST

AMOUNT

35





OTHER

COVERAGE

AMOUNT


Address

Address 00000



ANYTOWN CA 95814

Mary Smith MM DD YY

Prophy MM DD YY D1110 8500 9912345678

8500

MM DD YY

DC-217 (R 1019)

image1png

6 PATIENT ADDRESS

9


SERVICES

1

3

4

5

6

7

8

9

10

2

IMPORTANT NOTE

SIGNATURE DATE


X



DC-217 (R 1019)






CHECK IF YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES



HOW MANY_____________

11 CHECK IF

ACCIDENTINJURY

EMPLOYMENT RELATED









SERVICES






CITY STATE ZIP CODE


1 2 3 4 5 6 7 8

BIC Issue Date ________________

EVC _______________________


27 SURFACES



30 QUANTITY

31 PROCEDURE

NUMBER

32 FEE

33 RENDERING

PROVIDER NPI



AMOUNT

37 OTHER COVERAGE

AMOUNT

38 DATE BILLED


Address

Address 00000

X

9

X


Anytown CA 95814



80000

MM DD YY

Mary Smith MM DD YY

X



43B-PRL-TRN-006AC

6 PATIENT ADDRESS

9

MF-O


SERVICES

1

3

4

5

6

7

8

9

10

2

IMPORTANT NOTE

SIGNATURE

DATE



X






DC-217 (R 1019)


3 SEX

M F

4 PATIENT BIRTHDATE

MO DAY YR




CITY STATE

ZIP CODE

CHECK IF

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

P0 BOX 15610


Phone (800) 423-0507



HOW MANY_____________

11 CHECK IF

ACCIDENTINJURY

EMPLOYMENT RELATED

13 CHECK IF


14





16 CHDP CHECK IF

CHILD HEALTH AND


17 CCS


18 MF-O


SERVICES

10

OTHER ATTACHMENTS

12

ELIGIBILITY PENDING




CITY STATE ZIP CODE



1 2 3 4 5 6 7 8

BIC Issue Date ________________

EVC _______________________


26

TOOTHLTR

ARCHQUAD

27

SURFACES



29

DATE SERVICE

PERFORMED

30

QUANTITY

31

PROCEDURE

NUMBER

32

FEE

33

RENDERING

PROVIDER NPI

34 COMMENTS

35

TOTAL FEE

CHARGED

36 PATIENT

SHARE-OF-COST

AMOUNT

37 OTHER

COVERAGE

AMOUNT

38

DATE BILLED


Address

Address 00000

X

9

X


Anytown CA 95814





80000

MM DD YY

Mary Smith MM DD YY

X

IMPORTANT NOTICE






- TX section






image1png













44B-PRL-TRN-006AC











45B-PRL-TRN-006AC






39

X


34 COMMENTS




HOW MANY _________


41DELETE


3 SEXM F


23

16 CHDP


EMPLOYMENT RELATED

27SUR-FACES

28TOOTHNO OR

LETTERARCH

43 ADJREASON

CODE42ALLOWANCE

32FEE


31 PROCEDURENUMBER

30QTY

29 DATESERVICE

PERFORMED


35 TOTAL FEECHARGED

46 TOTALALLOWANCE


AMOUNT

38 DATEBILLED

37 OTHERCOVERAGE

AMOUNT

YES YES YES

YES

YES

YES


BIC Issue Date __________________

EVC _________________________



1

2

3

4

5

6

7

8

9

10

11

12

13

14

15





DATE

26





15550066100



YY318100124

1114YY0513YY

46B-PRL-TRN-006AC




FROM

TO

PAGE_____OF_____





39

X


34 COMMENTS

PO BOX 15609


Phone 800-423-0507


9


HOW MANY _________

10

OTHER ATTACHMENTS

41

DELETE



MO DAY YR

3 SEX

M F


23

16 CHDP


11

ACCIDENT INJURY

EMPLOYMENT RELATED

27

SUR-

FACES

28

TOOTH

NO OR

LETTER

ARCH

43 ADJ

REASON

CODE

42

ALLOWANCE

32

FEE

33 RENDERING

PROVIDER NO

31 PROCEDURE

NUMBER

30

QTY

29 DATE

SERVICE

PERFORMED

44 DATE PROSTHESIS

ORDERED

35 TOTAL FEE

CHARGED

46 TOTAL

ALLOWANCE

36 BENEFICIARY

SHARE-OF-COST

AMOUNT

38 DATE

BILLED

37 OTHER

COVERAGE

AMOUNT

YES

YES

YES

YES

YES

YES

CHECK IF

CHECK IF

CHECK IF

CHECK IF

BIC Issue Date __________________

EVC _________________________








1

2

3

4

5

6

7

8

9

10

11

12

13

14

15







BELOW IS


DATE

26

45 PROSTHESIS

LINE ITEM




3 O AmalgamD2140 5500 3900 355C




155500

66100



Anytown CA 95814


YY318100124

1114YY

0513YY



2 DCN










Box 33=





image1png









47B-PRL-TRN-006AC








EXAMPLE OF NOA


48B-PRL-TRN-006AC








5 Return the RTD to




49B-PRL-TRN-006AC

50B-PRL-TRN-006AC

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CHECKNoPROVIDER

No




ADJUDICATED CLAIMS





1234567899 00596352



CLAIM TOTAL 13200 10100 10100


ADJUSTMENT CLAIMS


CLAIM TOTAL - 19500 - 7800 - 7800


CLAIM TOTAL 19500 16300 16300



10100 8500 18600


1

2

3

4

5

6 7

8

9 10 11 12 13

14 15 16 17 18 19 20 21 22 23 24

25 26 27

BC STA-

TUSDATE

OF SERVICEPROCCODE

TOOTHCODE

DOCUMENTCONTROL NO

AMOUNTPAID

OTHERCOVERAGE

SHAREOF COST

ALLOWEDAMOUNT

AMOUNTBILLED

REASONCODE

BENE ID BIRTHDATE

ADJUSTMENT AMOUNT

53B-PRL-TRN-006AC


DENTI-CAL



CHECK

No

PROVIDER

No


P = PAID

D = DENIED

A= ADJUSTED

PLEASE CALL (800) 423-0507


BENEFICIARY NAME

MEDI-CAL

ID NO

SEX

ADJUDICATED CLAIMS

CLAIMS SPECIFIC

NON CLAIMS SPECIFIC

AMOUNT PAID

PAYABLES AMOUNT

LEVY AMOUNT

AR AMOUNT

CHECK AMOUNT




1234567899

00596352

Adams James DDS

30 Center Street

Anytown CA 95814

B LAST

FIRST

99999999D 99999999D M mmddyy

C YY163108181 D0150

0601YY P

2500 2500

2500

C

D0274

0601YY P

3000 1800 1800

C

D0230

0601YY P

3000 1800

1800

C

D1120

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4700

00 00

C D1110

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4700 4000

4000

CLAIM TOTAL

13200

10100

10100


13200 10100

10100

ADJUSTMENT CLAIMS

B LAST FIRST

99999999D 99999999D F mmddyy


C YY168101357 15 D7210

0610YY A 266B - 9500 - 00

- 00

C

14 D2140

0610YY A - 5000 - 3900 - 3900

C

13 D2140

0610YY A - 5000 - 3900 - 3900

CLAIM TOTAL - 19500 - 7800 - 7800

B LAST FIRST

99999999D 99999999D F mmddyy


C YY168101357 15 D7210

0610YY P 9500 8500 8500

C

14 D2140

0610YY P 5000 3900 3900

C

13 D2140

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CLAIM TOTAL 19500 16300 16300



13200

18600 18600

10100 8500 18600


of 3

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

B

C

STA-

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DATE

OF SERVICE

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CODE

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DOCUMENT

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PAID

OTHER

COVERAGE

SHARE

OF COST

ALLOWED

AMOUNT

AMOUNT

BILLED

REASON

CODE

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CHECKNoPROVIDER

No






AMOUNTPAID

ALLOWEDAMOUNT




005963521234567899












BC DOCUMENT

CONTROL NOOTHER

COVERAGESHARE

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REASONCODE

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54B-PRL-TRN-006AC

OTHER

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OF COST

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CHECK

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of 3


P = PAID

D = DENIED

A= ADJUSTED

PLEASE CALL (800) 423-0507


BENEFICIARY NAME

MEDI-CAL

ID NO

BENE ID

SEX

BIRTH

DATE

AMOUNT

PAID

ALLOWED

AMOUNT

CLAIMS SPECIFIC

NON CLAIMS SPECIFIC

AMOUNT PAID

ADJUSTMENT AMOUNT

PAYABLES AMOUNT

LEVY AMOUNT

AR AMOUNT

CHECK AMOUNT




00596352

1234567899

Adams James DDS

30 Center Street

Anytown CA 95814



----------------------------------------------------------------------------------------------------------------------------------------------------------------------






----------------------------------------------------------------------------------------------------------------------------------------------------------------------











+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++



FOR RESERVATIONS

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++



FOR RESERVATIONS

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++



FOR RESERVATIONS

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55B-PRL-TRN-006AC














56


B-PRL-TRN-006AC


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XSIGNATURE DATE



OPER ID ______________________________________

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58


B-PRL-TRN-006AC


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59B-PRL-TRN-006AC


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60B-PRL-TRN-006AC








61


B-PRL-TRN-006AC



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BIRTHDATE

ADJUSTMENT CLAIMS


1234567899 00596352


10100 8500 18600

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TOOTHCODE

PROCCODE

DATEOF SERVICE

STA-TUS

REASONCODE

AMOUNTBILLED

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AMOUNTPAID




CLAIM TOTAL -19500 - 7800 - 7800


CLAIM TOTAL 19500 16300 16300





62B-PRL-TRN-006AC



CHECK

No

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of 3


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D = DENIED

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PLEASE CALL (800) 423-0507


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NON CLAIMS SPECIFIC

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1234567899

00596352

Adams James DDS

30 Center Street

Anytown CA 95814

10100 8500 18600

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C YY168101357 15 D7210 1010YY A 266B - 9500 - 00 - 00

C 14 D2140 1010YY A - 5000 - 3900 - 3900

C 13 D2140 1010YY A - 5000 - 3900 - 3900

CLAIM TOTAL -19500 - 7800 - 7800



C YY168101357 15 D7210 1010YY P 9500 8500 8500

C 14 D2140 1010YY P 5000 3900 3900

C 13 D2140 1010YY P 5000 3900 3900

CLAIM TOTAL 19500 16300 16300



----------------------------------------------------------------------------------------------------------------------------------







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Slide Number 38



Slide Number 41

Slide Number 42

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Slide Number 46




Slide Number 50


Slide Number 52

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Slide Number 54

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Slide Number 56

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B-PRL-TRN-006AC 28


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PROCEDURE CODE




MEMBERS OVER 21



$1800 $1350 X


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$2200 $1650 X


$12000 $9000 X


$20000 $15000 X


$20000 $15000 X


$23000 $17250 X


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$3000 $2250 X


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B-PRL-TRN-006AC 30





B-PRL-TRN-006AC 31





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6 PATIENT ADDRESS

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3

4

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7

8

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4

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12

13

14

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DA T E

26





CHECKNoPROVIDERNo

DATE PAGE NO




ADJUDICATED CLAIMS


1234567891 00596352

081513 1of 3


CLAIM TOTAL 13200 10100 10100


ADJUSTMENT CLAIMS

10100 8500 18600

BC




AM OUNTPAID

OTHERCOVERAGE

SHAREOF COST

ALLOWEDAM OUNT

AM OUNTBILLED

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STA-TUS

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C D1110 060113 P S019 4700 4000 4000C D1120 060113 D R019 4700 00 00


CLAIM TOTAL -19500 - 7800 - 7800


CLAIM TOTAL 19500 16300 16300





CLAIM TAR NOA


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BIC Issue Date __________________

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DATE

PAGE NO


P = PAID

D = DENIED

A= ADJUSTED

PLEASE CALL (800) 423-0507


BENEFICIARY NAME

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ID NO

ADJUDICATED CLAIMS

CLAIMS SPECIFIC

NON CLAIMS SPECIFIC

1234567891

00596352

081513 1

of 3

Adams James DDS

30 Center Street

Anytown CA 95814

CLAIM TOTAL 13200 10100 10100


ADJUSTMENT CLAIMS

10100 8500 18600

B

C




BENE ID

SEX

BIRTH

DATE

AMOUNT

PAID

OTHER

COVERAGE

SHARE

OF COST

ALLOWED

AMOUNT

AMOUNT

BILLED

REASON

CODE

STA-

TUS

DATE

OF SERVICE

PROC

CODE

TOOTH

CODE

DOCUMENT

CONTROL NO

AR AMOUNT

LEVY AMOUNT

ADJUSTMENT AMOUNT

AMOUNT PAID

PAYABLES AMOUNT


C 13163108181 D0150060113 P 2500 2500 2500

C D0274060113 P 3000 1800 1800

C D0230060113 P 3000 1800 1800

C D1110060113 P S019 4700 4000 4000

C D1120060113 D R019 4700 00 00



C 13168101357 15 D7210061013 A 266B - 9500 - 00 - 00

C 14 D2140061013 A - 5000 - 3900 - 3900

C 13 D2140 061013 A - 5000 - 3900 - 3900

CLAIM TOTAL -19500 - 7800 - 7800



C 13168101357 15 D7210 061013 P 9500 8500 8500

C 14 D2140 061013 P 5000 3900 3900

C 13 D2140 061013 P 5000 3900 3900

CLAIM TOTAL 19500 16300 16300





1 Provider info

2 Check






PO BOX 15609


Phone 800-423-0507


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38B-PRL-TRN-006AC






39B-PRL-TRN-006AC












40B-PRL-TRN-006AC

6 PATIENT ADDRESS

9


SERVICES

1

3

4

5

6

7

8

9

10

2


SIGNATURE DATE


X



DC-217 (R 1019)






CHECK IF YES

YES

YES

YES

YES

YES

YES

YES

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YES

YES



HOW MANY_____________

11 CHECK IF

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CITY STATE ZIP CODE


1 2 3 4 5 6 7 8

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27 SURFACES



30 QUANTITY

31 PROCEDURE

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Address 00000

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41B-PRL-TRN-006AC

6 PATIENT ADDRESS

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7

8

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16 CHDP CHECK IF

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MM DD YY

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21 MAILING ADDRESS

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Mary Smith MM DD YY

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6 PATIENT ADDRESS

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1

3

4

5

6

7

8

9

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37 OTHER COVERAGE

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38 DATE BILLED


Address

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X

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Anytown CA 95814



80000

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Mary Smith MM DD YY

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43B-PRL-TRN-006AC

6 PATIENT ADDRESS

9

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1

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5

6

7

8

9

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44B-PRL-TRN-006AC











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YES YES YES

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BIC Issue Date __________________

EVC _________________________



1

2

3

4

5

6

7

8

9

10

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1

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ADJUDICATED CLAIMS





1234567899 00596352



CLAIM TOTAL 13200 10100 10100


ADJUSTMENT CLAIMS


CLAIM TOTAL - 19500 - 7800 - 7800


CLAIM TOTAL 19500 16300 16300



10100 8500 18600


1

2

3

4

5

6 7

8

9 10 11 12 13

14 15 16 17 18 19 20 21 22 23 24

25 26 27

BC STA-

TUSDATE

OF SERVICEPROCCODE

TOOTHCODE

DOCUMENTCONTROL NO

AMOUNTPAID

OTHERCOVERAGE

SHAREOF COST

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BENE ID BIRTHDATE

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53B-PRL-TRN-006AC


DENTI-CAL



CHECK

No

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P = PAID

D = DENIED

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PLEASE CALL (800) 423-0507


BENEFICIARY NAME

MEDI-CAL

ID NO

SEX

ADJUDICATED CLAIMS

CLAIMS SPECIFIC

NON CLAIMS SPECIFIC

AMOUNT PAID

PAYABLES AMOUNT

LEVY AMOUNT

AR AMOUNT

CHECK AMOUNT




1234567899

00596352

Adams James DDS

30 Center Street

Anytown CA 95814

B LAST

FIRST

99999999D 99999999D M mmddyy

C YY163108181 D0150

0601YY P

2500 2500

2500

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3000 1800 1800

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3000 1800

1800

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4700

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4700 4000

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CLAIM TOTAL

13200

10100

10100


13200 10100

10100

ADJUSTMENT CLAIMS

B LAST FIRST

99999999D 99999999D F mmddyy


C YY168101357 15 D7210

0610YY A 266B - 9500 - 00

- 00

C

14 D2140

0610YY A - 5000 - 3900 - 3900

C

13 D2140

0610YY A - 5000 - 3900 - 3900

CLAIM TOTAL - 19500 - 7800 - 7800

B LAST FIRST

99999999D 99999999D F mmddyy


C YY168101357 15 D7210

0610YY P 9500 8500 8500

C

14 D2140

0610YY P 5000 3900 3900

C

13 D2140

0610YY P 5000 3900 3900

CLAIM TOTAL 19500 16300 16300



13200

18600 18600

10100 8500 18600


of 3

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

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24

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26

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STA-

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OF SERVICE

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SHARE

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No






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ALLOWEDAMOUNT




005963521234567899












BC DOCUMENT

CONTROL NOOTHER

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54B-PRL-TRN-006AC

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00596352

1234567899

Adams James DDS

30 Center Street

Anytown CA 95814



----------------------------------------------------------------------------------------------------------------------------------------------------------------------






----------------------------------------------------------------------------------------------------------------------------------------------------------------------











+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++



FOR RESERVATIONS

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FOR RESERVATIONS

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FOR RESERVATIONS

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55B-PRL-TRN-006AC














56


B-PRL-TRN-006AC


CLAIM INQUIRY FORM











XSIGNATURE DATE



OPER ID ______________________________________

ACTION CODE ___________________________________

IMPORTANT


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CITY STATE ZIP CODE






Anytown CA 95814

Last First

99999999999999 MM DD YY

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MM DD YY

Mary Jones MM DD YY

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B-PRL-TRN-006AC


CLAIM INQUIRY FORM



PO BOX 15609


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X

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OPER ID ______________________________________

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58


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First Level Appeals

60B-PRL-TRN-006AC








61


B-PRL-TRN-006AC



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BIRTHDATE

ADJUSTMENT CLAIMS


1234567899 00596352


10100 8500 18600

CB



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TOOTHCODE

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DATEOF SERVICE

STA-TUS

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AMOUNTPAID




CLAIM TOTAL -19500 - 7800 - 7800


CLAIM TOTAL 19500 16300 16300





62B-PRL-TRN-006AC



CHECK

No

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of 3


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D = DENIED

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Adams James DDS

30 Center Street

Anytown CA 95814

10100 8500 18600

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C 14 D2140 1010YY A - 5000 - 3900 - 3900

C 13 D2140 1010YY A - 5000 - 3900 - 3900

CLAIM TOTAL -19500 - 7800 - 7800



C YY168101357 15 D7210 1010YY P 9500 8500 8500

C 14 D2140 1010YY P 5000 3900 3900

C 13 D2140 1010YY P 5000 3900 3900

CLAIM TOTAL 19500 16300 16300



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Provider Forms

Slide Number 38



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Slide Number 56

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~Data MMDDIYYYY 00



ff lC-


OOOOOAKEOR








MMIDDIYYYY 00

secondary carrier



IC_


23B-PRL-TRN-006AC


or family


bull Updating SOC

bull Case Numbers








24B-PRL-TRN-006AC








25B-PRL-TRN-006AC



Benefits Emergency

Full Scope aid code

Child (under 21)



DDS Member









26B-PRL-TRN-006AC

Pregnant Members





27B-PRL-TRN-006AC


Overview of CalAIM




B-PRL-TRN-006AC 28


--











B-PRL-TRN-006AC 29


PROCEDURE CODE




MEMBERS OVER 21



$1800 $1350 X


$800 $600 X


1800 $1350 X


$800 $600 X



$2200 $1650 X


$12000 $9000 X


$20000 $15000 X


$20000 $15000 X


$23000 $17250 X


$23000 $17250 X


$3000 $2250 X


$3000 $2250 X


$3000 $2250 X


$3000 $2250 X


$3000 $2250 X


$3000 $2250 X


$12000 $9000 X


$1000 $750 X


$4600 $3450 X

B-PRL-TRN-006AC 30





B-PRL-TRN-006AC 31





D1310



Low risk

Moderate risk

High Risk


($1500) ($4600)

D0601 D1310 6 months $6100

D0602 D1310 4 months $6100

D0603 D1310 3 months $6100

B-PRL-TRN-006AC 32





bull A benefit


Photograph required




B-PRL-TRN-006AC 33








D0120D0145D0150 X X

B-PRL-TRN-006AC 34













dentaldhcsca gov

B-PRL-TRN-006AC 35

0






Senate Bill 639






36B-PRL-TRN-006AC


6 PATIENT ADDRESS

9


SERVICES

1

3

4

5

6

7

8

9

10

2



SIGNATURE DATE


X



DC-217 (R0909)






CHECK IF YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES



HOW M ANY_____________

11 CHECK IF

ACCIDENTINJURY

EM PLOYMENT RELATED









SERVICES





CITY STATE ZIP CODE


BIC Issue Date ________________

EVC _______________________


27 SURFACES



30 Q UANTI TY

31 PROCEDURE

NUMBER

32 FEE

33 RENDERING

PROVIDER NO


CHARG ED


AM O UNT


AM O UNT

38 DATE BI LLED

wwwdenti -ca lcagov






39

X


34 COMMENTS




HOW M ANY _________


41DELETE


3 SEXM F


23

16 CHDP


EMPLOYMENT RELATED

27SUR-FACES

28TOOTHNO OR

LETTERARCH

43 ADJREASONCODE

42ALLOWANCE

32FEE


31 PROCEDURENUM BER

30QTY

29 DATESERVICE

PERFORMED


35 TOTAL FEECHARGED

46 TOTALALLOWANCE


AMOUNT

38 DATEBILLED

37 OTHERCOVERAGE

AMOUNT

YES YES YES

YES

YES

YES


BIC Issue Date __________________

EVC _________________________



1

2

3

4

5

6

7

8

9

10

11

12

13

14

15





DA T E

26





CHECKNoPROVIDERNo

DATE PAGE NO




ADJUDICATED CLAIMS


1234567891 00596352

081513 1of 3


CLAIM TOTAL 13200 10100 10100


ADJUSTMENT CLAIMS

10100 8500 18600

BC




AM OUNTPAID

OTHERCOVERAGE

SHAREOF COST

ALLOWEDAM OUNT

AM OUNTBILLED

REASONCODE

STA-TUS

DATEOF SERVICE

PROCCODE

TOOTHCODE

DOCUM ENTCONTROL NO



C D1110 060113 P S019 4700 4000 4000C D1120 060113 D R019 4700 00 00


CLAIM TOTAL -19500 - 7800 - 7800


CLAIM TOTAL 19500 16300 16300





CLAIM TAR NOA


NOTICEPAGE PAGES

OF


DOCUMENTCONTROL NO

AMOUNTBILLED




ITEMINFORMATION

BLOCKCLAIMFIELDNO

CLAIMLINE


ERRORCODE

ERROR DESCRIPTION





PATIENT NAME



XSIGNATURE DATE



DENTI-CAL USE ONLY

DCN


CLAIMTYPE

PAGE PAGES

OF

CLAIMFIELD NO

CLAIMLINE

ERRORCODE


CORRECT INFORMATION




01 01

PROCEDURECODE

A

B

37B-PRL-TRN-006AC

6 PATIENT ADDRESS

9

MF-O


SERVICES

1

3

4

5

6

7

8

9

10

2

IMPORTANT NOTE

IMPORTANT NOTICE





SIGNATURE

DATE



X






DC-217 (R0909)


3 SEX

M F

4 PATIENT BIRTHDATE

MO DAY YR




CITY STATE

ZIP CODE

CHECK IF

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

P0 BOX 15610


Phone (800) 423-0507



HOW MANY_____________

11 CHECK IF

ACCIDENTINJURY

EMPLOYMENT RELATED

13 CHECK IF


14





16 CHDP CHECK IF

CHILD HEALTH AND


17 CCS


18 MF-O


SERVICES

10

OTHER ATTACHMENTS

12

ELIGIBILITY PENDING




CITY STATE ZIP CODE



1 2 3 4 5 6 7 8

BIC Issue Date ________________

EVC _______________________


26

TOOTHLTR

ARCHQUAD

27

SURFACES



29

DATE SERVICE

PERFORMED

30

QUANTITY

31

PROCEDURE

NUMBER

32

FEE

33

RENDERING

PROVIDER NO

34 COMMENTS

35

TOTAL FEE

CHARGED

36 PATIENT

SHARE-OF-COST

AMOUNT

37 OTHER

COVERAGE

AMOUNT

38

DATE BILLED

wwwdenti-calcagov




3= sex

4= Bdate= modayyr

















TX Section




BOX 33 =









image1png




FROM

TO

PAGE_____OF_____





39

X


34 COMMENTS

PO BOX 15609


Phone 800- 423- 0507


9


HOW MANY _________

10

OTHER ATTACHMENTS

41

DELETE



MO DAY YR

3 SEX

M F


23

16 CHDP


11

ACCIDENT INJURY

EMPLOYMENT RELATED

27

SUR-

FACES

28

TOOTH

NO OR

LETTER

ARCH

43 ADJ

REASON

CODE

42

ALLOWANCE

32

FEE

33 RENDERING

PROVIDER NO

31 PROCEDURE

NUMBER

30

QTY

29 DATE

SERVICE

PERFORMED

44 DATE PROSTHESIS

ORDERED

35 TOTAL FEE

CHARGED

46 TOTAL

ALLOWANCE

36 BENEFICIARY

SHARE-OF-COST

AMOUNT

38 DATE

BILLED

37 OTHER

COVERAGE

AMOUNT

YES

YES

YES

YES

YES

YES

CHECK IF

CHECK IF

CHECK IF

CHECK IF

BIC Issue Date __________________

EVC _________________________







1

2

3

4

5

6

7

8

9

10

11

12

13

14

15







BELOW IS


DATE

26

45 PROSTHESIS

LINE ITEM


111413

051314



2 DCN










Box 33=









FROM

TO

PAGE_____OF_____





39

X


34 COMMENTS

DENTI-CAL


PO BOX 15609


Phone 800- 423- 0507


9


HOW MANY _________

10

OTHER ATTACHMENTS

41

DELETE



MO DAY YR

3 SEX

M F


23

16 CHDP


11

ACCIDENT INJURY

EMPLOYMENT RELATED

27

SUR-

FACES

28

TOOTH

NO OR

LETTER

ARCH

43 ADJ

REASON

CODE

42

ALLOWANCE

32

FEE

33 RENDERING

PROVIDER NO

31 PROCEDURE

NUMBER

30

QTY

29 DATE

SERVICE

PERFORMED

44 DATE PROSTHESIS

ORDERED

35 TOTAL FEE

CHARGED

46 TOTAL

ALLOWANCE

36 BENEFICIARY

SHARE-OF-COST

AMOUNT

38 DATE

BILLED

37 OTHER

COVERAGE

AMOUNT

YES

YES

YES

YES

YES

YES

CHECK IF

CHECK IF

CHECK IF

CHECK IF

BIC Issue Date __________________

EVC _________________________







1

2

3

4

5

6

7

8

9

10

11

12

13

14

15







BELOW IS


DATE

26

45 PROSTHESIS

LINE ITEM




3 O AmalgamD2140 5500 3900 355C




155500

66100



Anytown CA 95814


10318100124

111410

051311

31

B-PRL-TRN-005B



2 DCN










Box 33=





image2emf



FROMTO





39

X


34 COMMENTS

DENTI-CAL





HOW MANY _________


41

DELETE



27

SUR-FACES

28


43 ADJREASONCODE

42ALLOWANCE32FEE

33 RENDERING


NUMBER

30QTY


44 DATE PROSTHESIS

ORDERED

35 TOTAL FEECHARGED

46 TOTAL

ALLOWANCE

36 BENEFICIARY

SHARE-OF-COST

AMOUNT

38 DATEBILLED






1

23

4

5

67

8

9101112

13

1415





DATE

2645 PROSTHESIS

LINE ITEM





155500

66100



Anytown CA95814


10318100124

111410051311

31

B-PRL-TRN-005B

image1png


DENTI-CAL



CHECK

No

PROVIDER

No

DATE

PAGE NO


P = PAID

D = DENIED

A= ADJUSTED

PLEASE CALL (800) 423-0507


BENEFICIARY NAME

MEDI-CAL

ID NO

ADJUDICATED CLAIMS

CLAIMS SPECIFIC

NON CLAIMS SPECIFIC

1234567891

00596352

081513 1

of 3

Adams James DDS

30 Center Street

Anytown CA 95814

CLAIM TOTAL 13200 10100 10100


ADJUSTMENT CLAIMS

10100 8500 18600

B

C




BENE ID

SEX

BIRTH

DATE

AMOUNT

PAID

OTHER

COVERAGE

SHARE

OF COST

ALLOWED

AMOUNT

AMOUNT

BILLED

REASON

CODE

STA-

TUS

DATE

OF SERVICE

PROC

CODE

TOOTH

CODE

DOCUMENT

CONTROL NO

AR AMOUNT

LEVY AMOUNT

ADJUSTMENT AMOUNT

AMOUNT PAID

PAYABLES AMOUNT


C 13163108181 D0150060113 P 2500 2500 2500

C D0274060113 P 3000 1800 1800

C D0230060113 P 3000 1800 1800

C D1110060113 P S019 4700 4000 4000

C D1120060113 D R019 4700 00 00



C 13168101357 15 D7210061013 A 266B - 9500 - 00 - 00

C 14 D2140061013 A - 5000 - 3900 - 3900

C 13 D2140 061013 A - 5000 - 3900 - 3900

CLAIM TOTAL -19500 - 7800 - 7800



C 13168101357 15 D7210 061013 P 9500 8500 8500

C 14 D2140 061013 P 5000 3900 3900

C 13 D2140 061013 P 5000 3900 3900

CLAIM TOTAL 19500 16300 16300





1 Provider info

2 Check






PO BOX 15609


Phone 800-423-0507


CLAIM

TAR

NOA






NOTICE

PAGE PAGES

OF

RTD ISSUE DATE

RTD DUE DATE

DOCUMENT

CONTROL NO

AMOUNT

BILLED

BEGINNING

DATE OF SERVICE

PATIENT DENTAL

RECORD NO

PATIENT MEDI-CAL

ID NUMBER

PATIENT NAME

ITEM

INFORMATION

BLOCK

CLAIM

FIELD

NO

CLAIM

LINE

SUBMITTED

INFORMATION

ERROR

CODE

ERROR DESCRIPTION

RETAIN THIS PORTION





PATIENT NAME






X

SIGNATURE

DATE





DENTI-CAL USE ONLY

DCN


CLAIM

TYPE

PAGE

PAGES

OF

CLAIM

FIELD NO

CLAIM

LINE

ERROR

CODE




CORRECT INFORMATION



MAILING ADDRESS

CITY STATE ZIP CODE


01 01

PROCEDURE

CODE

A

B

10






image1png

































38B-PRL-TRN-006AC






39B-PRL-TRN-006AC












40B-PRL-TRN-006AC

6 PATIENT ADDRESS

9


SERVICES

1

3

4

5

6

7

8

9

10

2


SIGNATURE DATE


X



DC-217 (R 1019)






CHECK IF YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES



HOW MANY_____________

11 CHECK IF

ACCIDENTINJURY

EMPLOYMENT RELATED









SERVICES






CITY STATE ZIP CODE


1 2 3 4 5 6 7 8

BIC Issue Date ________________

EVC _______________________


27 SURFACES



30 QUANTITY

31 PROCEDURE

NUMBER

32 FEE

33 RENDERING

PROVIDER NPI



AMOUNT

37 OTHER COVERAGE

AMOUNT

38 DATE BILLED


Address

Address 00000

40900

MM DD YY

X

3

X






ANYTOWN CA 95814

mmddyy

123456789A1

41B-PRL-TRN-006AC

6 PATIENT ADDRESS

9

MF-O


SERVICES

1

3

4

5

6

7

8

9

10

2

IMPORTANT NOTICE



SIGNATURE

DATE



X






DC-217 (R 1019)


3 SEX

M F

4 PATIENT BIRTHDATE

MO DAY YR




CITY STATE

ZIP CODE

CHECK IF

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

P0 BOX 15610


Phone (800) 423-0507



HOW MANY_____________

11 CHECK IF

ACCIDENTINJURY

EMPLOYMENT RELATED

13 CHECK IF


14





16 CHDP CHECK IF

CHILD HEALTH AND


17 CCS


18 MF-O


SERVICES

10

OTHER ATTACHMENTS

12

ELIGIBILITY PENDING




CITY STATE ZIP CODE



1 2 3 4 5 6 7 8

BIC Issue Date ________________

EVC _______________________


26

TOOTHLTR

ARCHQUAD

27

SURFACES



29

DATE SERVICE

PERFORMED

30

QUANTITY

31

PROCEDURE

NUMBER

32

FEE

33

RENDERING

PROVIDER NPI

34 COMMENTS

35

TOTAL FEE

CHARGED

36 PATIENT

SHARE-OF-COST

AMOUNT

37 OTHER

COVERAGE

AMOUNT

38

DATE BILLED


Address

Address 00000

40900

MM DD YY

X

3

X

Exam MM DD YY D0150 2500 9912345678








ANYTOWN CA 95814




3= sex

4= Bdate= modayyr

















TX Section




BOX 33 =






BILLING LIMITATIONS



image1png





3SEXM F






6PATIENT ADDRESS

CITY STATE

9 YESCHECK IF


HOW MANY_____________

YES

11ACCIDENTINJURY

EMPLOYMENT RELATED

CHECK IF YES

YES

YES





YES

YES

YES

16

17

18





SERVICES

YES

YES

YES





HOSPITALIN-PATIENT




28 32FEE

33RENDERING

PROVIDER NPI

CHECK IF CHECK IF

1

3

4

5

6

7

8

9

10

2


36

37

38 DATEBILLED


SIGNATURE DATE


X



SERVICES



10

OTHER ATTACHMENTS


EVC 123456789A1

1 2 3 4 5 6 7 8


27SURFACES

30QUANTITY

31PROCEDURE

NUMBER



AMOUNT

35


OTHER COVERAGE

AMOUNT


Address

Address 00000



ANYTOWN CA 95814

Mary Smith MM DD YY

Prophy MM DD YY D1110 8500 9912345678

8500

MM DD YY

DC-217 (R 1019)

1

1 2

3

4

42B-PRL-TRN-006AC

PO BOX 15610


Phone 800-423-0507


3SEX

M F

4PATIENT BIRTHDATE

MO DAY YR



ZIP CODE



6PATIENT ADDRESS

CITY STATE

9

YES

CHECK IF


HOW MANY_____________

YES

11

ACCIDENTINJURY

EMPLOYMENT RELATED

CHECK IF

YES

YES

YES

13


14





YES

YES

YES

16

17

18

CHDP

CHILD HEALTH AND


ccs


MF-O


SERVICES

YES

YES

YES



21 MAILING ADDRESS

TELEPHONE NUMBER

( )

CITY STATE

ZIP CODE

22 PLACE OF SERVICE


HOSPITAL

IN-PATIENT

HOSPITAL

OUT-PATIENT

OTHER

(PLEASE SPECIFY)


26

TOOTHLTR

ARCHQUAD

28

32

FEE

33

RENDERING

PROVIDER NPI

CHECK IF

CHECK IF

1

3

4

5

6

7

8

9

10

2

34 COMMENTS

TOTAL FEE

CHARGED

36

37

38

DATE

BILLED

IMPORTANT NOTE

IMPORTANT NOTICE



SIGNATURE

DATE



X


MF-O


SERVICES

12

ELIGIBILITY PENDING


10

OTHER ATTACHMENTS


EVC 123456789A1

1 2 3 4 5 6 7 8



27

SURFACES

30

QUANTITY

31

PROCEDURE

NUMBER

29

DATE SERVICE

PERFORMED

PATIENT

SHARE- OF- COST

AMOUNT

35





OTHER

COVERAGE

AMOUNT


Address

Address 00000



ANYTOWN CA 95814

Mary Smith MM DD YY

Prophy MM DD YY D1110 8500 9912345678

8500

MM DD YY

DC-217 (R 1019)

image1png

6 PATIENT ADDRESS

9


SERVICES

1

3

4

5

6

7

8

9

10

2

IMPORTANT NOTE

SIGNATURE DATE


X



DC-217 (R 1019)






CHECK IF YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES



HOW MANY_____________

11 CHECK IF

ACCIDENTINJURY

EMPLOYMENT RELATED









SERVICES






CITY STATE ZIP CODE


1 2 3 4 5 6 7 8

BIC Issue Date ________________

EVC _______________________


27 SURFACES



30 QUANTITY

31 PROCEDURE

NUMBER

32 FEE

33 RENDERING

PROVIDER NPI



AMOUNT

37 OTHER COVERAGE

AMOUNT

38 DATE BILLED


Address

Address 00000

X

9

X


Anytown CA 95814



80000

MM DD YY

Mary Smith MM DD YY

X



43B-PRL-TRN-006AC

6 PATIENT ADDRESS

9

MF-O


SERVICES

1

3

4

5

6

7

8

9

10

2

IMPORTANT NOTE

SIGNATURE

DATE



X






DC-217 (R 1019)


3 SEX

M F

4 PATIENT BIRTHDATE

MO DAY YR




CITY STATE

ZIP CODE

CHECK IF

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

P0 BOX 15610


Phone (800) 423-0507



HOW MANY_____________

11 CHECK IF

ACCIDENTINJURY

EMPLOYMENT RELATED

13 CHECK IF


14





16 CHDP CHECK IF

CHILD HEALTH AND


17 CCS


18 MF-O


SERVICES

10

OTHER ATTACHMENTS

12

ELIGIBILITY PENDING




CITY STATE ZIP CODE



1 2 3 4 5 6 7 8

BIC Issue Date ________________

EVC _______________________


26

TOOTHLTR

ARCHQUAD

27

SURFACES



29

DATE SERVICE

PERFORMED

30

QUANTITY

31

PROCEDURE

NUMBER

32

FEE

33

RENDERING

PROVIDER NPI

34 COMMENTS

35

TOTAL FEE

CHARGED

36 PATIENT

SHARE-OF-COST

AMOUNT

37 OTHER

COVERAGE

AMOUNT

38

DATE BILLED


Address

Address 00000

X

9

X


Anytown CA 95814





80000

MM DD YY

Mary Smith MM DD YY

X

IMPORTANT NOTICE






- TX section






image1png













44B-PRL-TRN-006AC











45B-PRL-TRN-006AC






39

X


34 COMMENTS




HOW MANY _________


41DELETE


3 SEXM F


23

16 CHDP


EMPLOYMENT RELATED

27SUR-FACES

28TOOTHNO OR

LETTERARCH

43 ADJREASON

CODE42ALLOWANCE

32FEE


31 PROCEDURENUMBER

30QTY

29 DATESERVICE

PERFORMED


35 TOTAL FEECHARGED

46 TOTALALLOWANCE


AMOUNT

38 DATEBILLED

37 OTHERCOVERAGE

AMOUNT

YES YES YES

YES

YES

YES


BIC Issue Date __________________

EVC _________________________



1

2

3

4

5

6

7

8

9

10

11

12

13

14

15





DATE

26





15550066100



YY318100124

1114YY0513YY

46B-PRL-TRN-006AC




FROM

TO

PAGE_____OF_____





39

X


34 COMMENTS

PO BOX 15609


Phone 800-423-0507


9


HOW MANY _________

10

OTHER ATTACHMENTS

41

DELETE



MO DAY YR

3 SEX

M F


23

16 CHDP


11

ACCIDENT INJURY

EMPLOYMENT RELATED

27

SUR-

FACES

28

TOOTH

NO OR

LETTER

ARCH

43 ADJ

REASON

CODE

42

ALLOWANCE

32

FEE

33 RENDERING

PROVIDER NO

31 PROCEDURE

NUMBER

30

QTY

29 DATE

SERVICE

PERFORMED

44 DATE PROSTHESIS

ORDERED

35 TOTAL FEE

CHARGED

46 TOTAL

ALLOWANCE

36 BENEFICIARY

SHARE-OF-COST

AMOUNT

38 DATE

BILLED

37 OTHER

COVERAGE

AMOUNT

YES

YES

YES

YES

YES

YES

CHECK IF

CHECK IF

CHECK IF

CHECK IF

BIC Issue Date __________________

EVC _________________________








1

2

3

4

5

6

7

8

9

10

11

12

13

14

15







BELOW IS


DATE

26

45 PROSTHESIS

LINE ITEM




3 O AmalgamD2140 5500 3900 355C




155500

66100



Anytown CA 95814


YY318100124

1114YY

0513YY



2 DCN










Box 33=





image1png









47B-PRL-TRN-006AC








EXAMPLE OF NOA


48B-PRL-TRN-006AC








5 Return the RTD to




49B-PRL-TRN-006AC

50B-PRL-TRN-006AC

_vn 1vnr

GJ T AR

- rrullENT

NOA



Pn o n e 800423 -0 507 lt -- C~~M




Ad ams James DDS


1234567899 NOTICE

PAGE m__ OF I

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26 04 ~

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(member)rdquo















51B-PRL-TRN-006AC















52


B-PRL-TRN-006AC



CHECKNoPROVIDER

No




ADJUDICATED CLAIMS





1234567899 00596352



CLAIM TOTAL 13200 10100 10100


ADJUSTMENT CLAIMS


CLAIM TOTAL - 19500 - 7800 - 7800


CLAIM TOTAL 19500 16300 16300



10100 8500 18600


1

2

3

4

5

6 7

8

9 10 11 12 13

14 15 16 17 18 19 20 21 22 23 24

25 26 27

BC STA-

TUSDATE

OF SERVICEPROCCODE

TOOTHCODE

DOCUMENTCONTROL NO

AMOUNTPAID

OTHERCOVERAGE

SHAREOF COST

ALLOWEDAMOUNT

AMOUNTBILLED

REASONCODE

BENE ID BIRTHDATE

ADJUSTMENT AMOUNT

53B-PRL-TRN-006AC


DENTI-CAL



CHECK

No

PROVIDER

No


P = PAID

D = DENIED

A= ADJUSTED

PLEASE CALL (800) 423-0507


BENEFICIARY NAME

MEDI-CAL

ID NO

SEX

ADJUDICATED CLAIMS

CLAIMS SPECIFIC

NON CLAIMS SPECIFIC

AMOUNT PAID

PAYABLES AMOUNT

LEVY AMOUNT

AR AMOUNT

CHECK AMOUNT




1234567899

00596352

Adams James DDS

30 Center Street

Anytown CA 95814

B LAST

FIRST

99999999D 99999999D M mmddyy

C YY163108181 D0150

0601YY P

2500 2500

2500

C

D0274

0601YY P

3000 1800 1800

C

D0230

0601YY P

3000 1800

1800

C

D1120

0601YY

D R019

4700

00 00

C D1110

0601YY P S019

4700 4000

4000

CLAIM TOTAL

13200

10100

10100


13200 10100

10100

ADJUSTMENT CLAIMS

B LAST FIRST

99999999D 99999999D F mmddyy


C YY168101357 15 D7210

0610YY A 266B - 9500 - 00

- 00

C

14 D2140

0610YY A - 5000 - 3900 - 3900

C

13 D2140

0610YY A - 5000 - 3900 - 3900

CLAIM TOTAL - 19500 - 7800 - 7800

B LAST FIRST

99999999D 99999999D F mmddyy


C YY168101357 15 D7210

0610YY P 9500 8500 8500

C

14 D2140

0610YY P 5000 3900 3900

C

13 D2140

0610YY P 5000 3900 3900

CLAIM TOTAL 19500 16300 16300



13200

18600 18600

10100 8500 18600


of 3

1

2

3

4

5

6

7

8

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005963521234567899












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54B-PRL-TRN-006AC

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BENEFICIARY NAME

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AMOUNT

PAID

ALLOWED

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CLAIMS SPECIFIC

NON CLAIMS SPECIFIC

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00596352

1234567899

Adams James DDS

30 Center Street

Anytown CA 95814



----------------------------------------------------------------------------------------------------------------------------------------------------------------------






----------------------------------------------------------------------------------------------------------------------------------------------------------------------











+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++



FOR RESERVATIONS

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++



FOR RESERVATIONS

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++



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55B-PRL-TRN-006AC














56


B-PRL-TRN-006AC


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XSIGNATURE DATE



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58


B-PRL-TRN-006AC


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XSIGNATURE DATE



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59B-PRL-TRN-006AC


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60B-PRL-TRN-006AC








61


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1234567899 00596352


10100 8500 18600

CB



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TOOTHCODE

PROCCODE

DATEOF SERVICE

STA-TUS

REASONCODE

AMOUNTBILLED

ALLOWEDAMOUNT

SHAREOF COST

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CLAIM TOTAL -19500 - 7800 - 7800


CLAIM TOTAL 19500 16300 16300





62B-PRL-TRN-006AC



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D = DENIED

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ADJUSTMENT CLAIMS

CLAIMS SPECIFIC

NON CLAIMS SPECIFIC

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1234567899

00596352

Adams James DDS

30 Center Street

Anytown CA 95814

10100 8500 18600

C

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CODE

DATE

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C YY168101357 15 D7210 1010YY A 266B - 9500 - 00 - 00

C 14 D2140 1010YY A - 5000 - 3900 - 3900

C 13 D2140 1010YY A - 5000 - 3900 - 3900

CLAIM TOTAL -19500 - 7800 - 7800



C YY168101357 15 D7210 1010YY P 9500 8500 8500

C 14 D2140 1010YY P 5000 3900 3900

C 13 D2140 1010YY P 5000 3900 3900

CLAIM TOTAL 19500 16300 16300



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