My team has echoed the same concerns. Jan's solution works and makes sense
if the Provider sends one tooth per line.
It is the case where the provider sends multiple services for multiple
teeth on one line and one service/ one tooth may get denied (i.e.
Multiple extractions) that causes us concern. We can split the line,
process the lines separately and deny the appropriate service. However,
when the Provider gets the claim lines back, he will not know which tooth's
service was denied, since we cannot give him the tooth number.
Terri Dickson
DVS HIPAA Project Manager
Dental & Vision Systems
Highmark
717.731.2449
Jan Root
<janroot@uhin. To: [EMAIL PROTECTED]
com> cc: [EMAIL PROTECTED]
Subject: Re: Tooth Number on 835 -Reply
02/01/2002
11:28 AM
Can I chime in with one small addition? In the Dental 837 there is the
option of using the
Line Item Control Number to identify specific service lines in the
claim/encounter. This is
a situational REF in the 837. The provider can label each line "1", "2",
"3", etc. (you
don't need to use a big number). If the provider puts a Line control
number in the 837
service lines, the payer must keep it associated with the correct service
line and return it
in the 835. Using this REF would allow the provider to identify specific
lines (specific
payments) without having the tooth information in the 835. So, the final
exchange could look
something like this:
837
CLM01 = 467834463 (a number unique to this particular claim)
Line 1: Tooth 30, Charge $40, Control Number 1
Line 2: Tooth 12, Charge $40, Control Number 2
Line 3: Tooth 6, Charge $40, Control Number 3
Line 4: Tooth 23, Charge $40, Control Number 4
Line 5: Tooth 15, Charge $40, Control Number 5
835
CLP01 = 467834463
Line 1: Charge $40, Paid $35 control number 4
Line 2: Charge $40, Paid $35, control number 3
Line 3: Charge $40, Paid $24, control number 1
Line 4: Charge $40, Paid $27, control number 2
Line 5: charge $40, Paid $35, control number 5
The provider know that control number 5 refers to tooth 15, control number
2 = tooth 12,
etc. Does that help?
Jan
Kepa Zubeldia wrote:
> Bruce,
>
> I am not sure we are talking about the same things... The claim allows
> you to specify up to 32 teeth, and up to 5 surfaces per tooth. All in
> the TOO segment. And one of these multi-teeth-multi-surface description
> sets for each service. It is all there in the claim.
>
> The remittance advice refers to the service in the claim, but there is
> no need to echo all the TOO segments back with the payment. The
> provider already knows about them.
>
> Does it make more sense now?
>
> Kepa
>
> Bruce Silverman wrote:
> >
> > No
> >
> > In the dental world where many teeth are included on a claim
> > and many variations in benefits can occur, teeth numbers
> > and surfaces are very important
> >
> > Bruce Silverman
> > Sr. VP, Claims & Customer Service
> > Delta Dental Plan of New Jersey
> >
> > >>> Kepa Zubeldia <[EMAIL PROTECTED]> 11/30/01
> > 10:27pm >>>
> > Greg,
> >
> > Further explanation. The tooth number is filed in the claim
> > and does
> > NOT need to be returned in the 835. There is no reason to
> > change the
> > tooth number from that filed in the claim, and there is no
> > reason to
> > communicate the tooth number back to the provider, since
> > the provider
> > already knows and already sent it in the claim.
> >
> > Does that make sense?
> >
> > Kepa
> >
> > [EMAIL PROTECTED] wrote:
> > >
> > > We have been analyzing implementing Dental 835 and
> > have found there is no
> > > field to accomodate Tooth Number at the Procedure level
> > on the 835 spec.
> > >
> > > Has anyone else encountered this problem? Did you find a
> > solution?
> > >
> > > This is an issue for us as duplicate procedures could occur
> > on different teeth.
> > >
> > > thanks
> > >
> > > Greg Monroe
> > > Wellpoint
> > > EDI Technical Specialist
> > > [EMAIL PROTECTED]
> > > (818) 234-1024
> > >
> > >
> > **********************************************************************
> > > To be removed from this list, go to:
> > http://snip.wedi.org/unsubscribe.cfm?list=business
> > > and enter your email address.
> >
> > **********************************************************************
> > To be removed from this list, go to:
> > http://snip.wedi.org/unsubscribe.cfm?list=business
> > and enter your email address.
> >
> > **********************************************************************
> > To be removed from this list, go to:
http://snip.wedi.org/unsubscribe.cfm?list=business
> > and enter your email address.
>
> **********************************************************************
> To be removed from this list, go to:
http://snip.wedi.org/unsubscribe.cfm?list=business
> and enter your email address.
**********************************************************************
To be removed from this list, go to:
http://snip.wedi.org/unsubscribe.cfm?list=business
and enter your email address.
**********************************************************************
To be removed from this list, go to: http://snip.wedi.org/unsubscribe.cfm?list=business
and enter your email address.
