Patient Transaction Screen – Insurance Claims and Pre-Authorizations

Insurance claims and pre-authorizations can be printed immediately or batched for later printing. In addition, insurance claims can be sent electronically.

MOGO will know if a claim is a pre-authorization since there will be no date under the Date column for treatment on the patient Transaction screen. When an insurance pre-authorization is printed, MOGO will enter a code on the Transaction screen. (e.g., AP-Blue Cross, which will show the total amount of the pre-authorization along with the date the form printed and the insurance estimated amount). Note: “AP” is Authorization Primary and “AS” is Authorization Secondary.

When you receive a pre-authorization back from the insurance company, you will enter the date that it was received in the Acc.Date column on the same line as the insurance code. This will stop the claim from being tracked on the Past Due Pre-Authorization Report.

A claim for payment will have a date under the Date column for treatment. When an insurance claim is printed, MOGO will enter a code on the Transaction screen (e.g., CP-Blue Cross, which will show the total amount of the claim along with the date the form printed and the insurance estimated amount). Note: “CP” is an abbreviation for “Claim Primary” and “CS” is an abbreviation for “Claim Secondary”.

Insurance claims and pre-authorizations are tracked in the To Do List under the Tx Status tab. You can view and re-print previously printed insurance claims as well as electronic insurance claims. Right click on a past due insurance claim or pre-authorization to open the popup menu. Select “View Claim Form”. The previously printed form will be sent to the screen. You will be prompted for page numbers when viewing multiple page insurance forms.

There will be an option at the top of the insurance form selection screen to “Claim all treatment on Medical Form”. This will allow you to include any selected dental treatment on the HCFA medical claim form.

You can select from the following insurance form types:

• ADA 94 form
  • This is the standard ADA 94 form. There is a limitation of 100 characters per line in a Remarks field on the ADA 94 form.
• ADA 2000 form
  • This is the ADA 2000 form, which is used with the CDT-3 or “D” codes.
  • The form will allow eight (8) transaction lines per page.
  • There is a limitation of 70 characters per line in a Remarks field on the ADA 2000 form.
  • The Auto Accident field has an area for a description and date when you process the ADA 2000 form.
  • School information can be selected in the Options screen for the ADA 2000 form. Student Status is not required for the ADA 2000 form. The school name and address prints on the ADA 2000 form.
• ADA 2002 form
  • This is the ADA 2002 form, which is used with the CDT-4 codes. The form will allow ten (10) transaction lines per page.
  • If the insured family member’s relationship is marked as “Child”, and if they are 19 years of age or older, you will be asked to select their student status. You will be asked this question when you process an electronic claim or the ADA 2002 or ADA 2006 forms.
  • If the insured family member’s relationship is marked as “Other”, and if they are 19 years of age or older, you will be asked to select their student status when processing the ADA 2002 or ADA 2006 forms. You cannot select a relationship of “Other” when processing electronic claims.
  • Due to HIPAA regulations, the student status must be selected each time you process the ADA 2002 or ADA 2006 forms or an electronic claim.
  • The student status can also be selected by clicking on the Options button on the insurance form screen. Options information does not save due to HIPAA regulations.
  • School information is not required on the ADA 2002 or ADA 2006 forms or for electronic claims due to HIPAA regulations.
  • Auto Accident is limited to a two-letter state abbreviation and date for the ADA 2002and ADA 2006 forms and electronic claims.
  • The Treating Dentist and Treatment Location can be selected by clicking on the Options button. This is available for the ADA 2002 and ADA 2006 forms and electronic claims. The Treating Dentist information is then shown in fields 53-58 on the ADA 2002 form. If you do not select a Treating Dentist, these fields will default to the “Name of Billing Dentist” information.
• ADA 2006 form
  • The ADA 2006 claim form can be used with the CDT-7 codes. The form will allow ten (10) transaction lines per page.
  • The National Provider Identifier (NPI#) can be included on the ADA 2006 form. The NPI# is entered on the Provider Information screen.
  • A Group NPI# can be typed directly on the ADA 2006 form when the Billing Dentist or Dental Entity is marked as “Practice”. MOGO will ask if you want to save this information.
  • If the insured family member’s relationship is marked as “Child”, and if they are 19 years of age or older, you will be asked to select their student status. You will be asked this question when you process either an electronic claim or the ADA 2006 form.
  • If the insured family member’s relationship is marked as “Other”, and if they are 19 years of age or older, you will be asked to select their student status when processing the ADA 2006 form. You cannot select a relationship of “Other” when processing electronic claims.
  • Due to HIPAA regulations, the student status (if needed) must be selected each time you process either the ADA 2006 form or an electronic claim.
  • The student status can also be selected by clicking on the Options button on the insurance form screen. Options information does not save due to HIPAA regulations.
  • School information is not required on the ADA 2006 form or for electronic claims due to HIPAA regulations.
  • Auto Accident is limited to a two-letter state abbreviation and date for the ADA 2006 form and electronic claims.
  • The Treating Dentist and Treatment Location can be selected by clicking on the Options button. This is available for both the ADA 2006 form and electronic claims. The Treating Dentist information is then shown in fields 53-58 on the ADA 2006 form. If you do not select a Treating Dentist, these fields will default to the “Name of Billing Dentist” information. Note: If you change the Place of Treatment in field 38 from Provider’s Office to Hospital, ECF, or Other, then the Treating Dentist fields will be blank except for the date. In these cases, you can always select the Treating Dentist in Options if needed.
• ADA 2012 form
  • ‘Other Fee(s)’ has been changed from field #32 to field #31a
  • ‘Total Fee’ has been changed from field #33 to field #32
  • ‘Missing Teeth’ has been changed from field #34 to field #33
  • Field #34 and #34a have been updated to allow diagnosis codes to be linked to the claim.
• Ohio Medicaid
  • This is the Ohio Medicaid claim form.
• Denti-Cal
  • This is the California Medical Dental Program. The form has a limitation of fifteen (15) transaction lines per claim form.
  • The Patient Medi-Cal ID No. in box 5 is from the Case # field on the Patient Information screen.
  • The Medi-Cal Provider # in box 20 is from the Provider Medicaid # field on the Provider editing screen. This is the Provider from their Patient Information screen. Box 33 contains the same Provider # as box 20.
  • When you select this form, you will be given the option to change the top and left printout margins in order to conform to your printer. The margins cannot exceed 3 inches. If you enter more than 15 transactions, or set the margins to more than 3 inches, you will receive a message regarding these limitations.
• Denti-Cal 2007
  • This is the most current Denti-Cal form and the format is based on strict specifications from Denti-Cal. For example, the text will appear in ALL CAPS.
  • The Denti-Cal 2007 is a combined Treatment Authorization Request (TAR) and Claim Form.
  • CDT-4 codes (“D” codes) can be used with the Denti-Cal 2007 form.
  • The patient’s Social Security Number and tooth chart are not shown on this form.
  • The Patient Medi-Cal Benefits ID Card Number (box 5) is from the Case Number field on the Patient Information screen.
  • The Billing Provider Number (box 20) is the Billing Provider NPI#. The provider’s NPI# is entered on the Provider Information screen.
  • A Group NPI# can be entered when the Billing Dentist or Dental Entity box is marked as “Practice”. The Group NPI# will appear in box 20 on the Denti-Cal 2007 claim form.
  • The Rendering Provider Number (box 33) is the treating provider’s NPI# and will be shown for each line of treatment.
  • The BIC (Benefits Identification Card) Issue Date and EVC# (Eligibility Verification Card Number) can be typed in these fields on the insurance processing screen. This information is not saved.
• Electronic Claim
  • This is used for processing Electronic Insurance claims. There is a limit of 30 characters per line for electronic claims.
  • If the insured family member’s relationship is marked as child, and if they are 19 years of age or older, you will be asked to select their student status. You will be asked this question when you process either an electronic claim or the ADA 2006 form. You cannot select a relationship of other for electronic claims. Note: Due to HIPAA regulations, the student status must be selected each time you process either the ADA 2006 form or an electronic claim.
  • The student status can also be selected by clicking on the Options button on the insurance form screen. Options information does not save due to HIPAA regulations.
  • School information is not required on the ADA 2006 form or for electronic claims due to HIPAA regulations.
  • The radiograph area is disabled if you have selected electronic claim.
  • Auto Accident is limited to a two-letter state abbreviation and date for the ADA 2006 form and electronic claims.
  • The Treating Dentist and Treatment Location can be selected by clicking on the Options button. This is available for both the ADA 2006 form and electronic claims.
• Attending Physician’s Report
  • To print the Attending Physician’s Report.