to display details about how to complete the given field.As you use the Web Claims Submission form, be aware that you can click an Info icon to display details about how to complete the given field.
To use the Web Claim Submission form:
Starting with the Web Claims Submission Form section at the top, choose a Type from the drop-down list:
Select New Claim if you are submitting a new claim for this patient.
Select Pre-Treatment Estimate if you want an estimate of benefits.
In the Subscriber Information section, the following fields are required:
First; Last; Subscriber ID (Enter the Subscriber ID displayed on the ID card; the field accepts from 5 to 20 alphanumeric characters; if you cannot locate the ID from the card, you may enter the subscriber's SSN); DOB (Date of Birth); Gender; Addr1; City; State; Postal Code; Country.
In the Patient Information section, choose an option from the Patient drop-down list:
Select Subscriber if the patient and the subscriber are the same person. Required Patient Information data fields will be grayed out.
Select Other if the patient is a spouse or dependent. You then also need to complete the following fields: First; Last; DOB; Gender; Rel (Relationship to the Subscriber); FTS (Full Time Student -- note that FTS is not required if you've set the Rel field to Dependent Child ).
From the Other Dental Coverage drop-down list, choose either Y or N.
If you choose Y, the fields Other Subscriber ID, Other Carrier Pymt Amt, and Other Subscriber DOB are enabled. Use these fields when other coverage exists that may partially pay for a claim. Note that if you enter any value in the Other Carrier Pymt Amt field, the Primary Paid Amt field in the Fees section below will be disabled.
From the Ancillary Information section, choose an option from the Orthodontic Treatment drop-down list:
If you choose Y, you must then complete the Date Appliance Placed and Total Months of Treatments fields.
From the Prosthesis drop-down list, choose either Y or N.
If you choose Y, you must then choose an option from the Type drop-down list.
If you set Type to Replacement, you must then enter a Date of Prior Placement.
In the Fees section, the required fields are Date of Service; Code (be aware that you can click the Code link to display the Code Lookup page in a separate window); Fee (you do not need to enter the dollar sign, decimal point, or the two zeros) and Tooth System (JP is the default). Note the following:
The Description field will be auto-filled based on the Code entered.
If you entered a value in the Other Carrier Pymt field in the Patient Information section above, the Primary Paid Amt section will be unavailable.
If applicable, mark the Authorization and the AOB check boxes located below the Date of Service fields. You can also type notes into the Clinical Notes field.
In the Treating Dentist section, if you've previously submitted a claim via this form, simply mark the Copy from previous claim submission check box to auto-fill the required fields in this section. If you haven't submitted a claim previously via this form, be aware that the required fields are License, Individual NPI, First, Last, TIN (note that the TIN must be 9 numbers), Addr1, City, State, Postal Code, and Country (default is USA).
In the Attachments section, choose a Delivery Method option for sending supporting documentation. (If you do not have any attachments, choose No Attachments, and then skip ahead to the next step.) When choosing Fax Attachment, Mail Attachment, or Attach to this Claim, you must also enter the Attachment Control Nbr. (Enter your internal reference number associated with this claim as this will ensure the claim will be matched to your attachment. Use the same Attachment Control Number for all attachments connected to this claim.)
Mail Attachment: Mail the attachment to the address listed on the subscriber's ID card.
Fax Attachment: Fax the attachment to 1-866-516-5616.
Attach To This Claim: After entering the Attachment Control Nbr, add attachments as follows:
Choose an Attachment Type from the drop-down list. To add the attachment:
Click the Browse button, use the Choose file dialog box to navigate to the file, and then select the file and click Open, or double-click the file. Its path and name will appear in the Electronic Attachments field.
Click Attach. The file name appears below the Electronic Attachments field.
If necessary, continue to attach additional files in this manner.
To remove an attachment, click the Remove link to the right of the file name.
When you're ready to submit the form, click the Submit and Print button located toward the bottom right corner of the form.
If there are any errors or missing information, those fields will be outlined in red, and a related error message will appear. Resolve these errors, and then click Submit and Print again.
If the form was completed correctly, the Submission Confirmation screen will appear, as shown below.
