Step 11 - ADA-J400 Specs

Training Video

http://youtu.be/1mWOFXw3610

This chapter is extremely useful when you find an error on your scoring report that you want to locate in ClaimGear and correct.


The scoring report provides a box number and lists the data entry error.  Locate this box number on the Specs (see page 91).  The Specs provide instructions on how to navigate through ClaimGear to the exact field an error has occurred.  Make the corrections and click the Save button.




ADA-J400 Claim Form 

Below is an example of the ADA-J400 claim form.  The box numbers referred to on the scoring report and on the Specs are also on the box numbers on the ADA-J400 claim form.

 
 
 

 ADA-J400 Specs

CLAIMGEAR  ADA-J400 SPECS

BOX              DESCRIPTION OF FIELD ON FORM AND IN CLAIMGEAR

                      LOCATION OF FIELD IN CLAIMGEAR

 


 

1

 

Type of Transaction

 

 

Claim -F1 tab, 1 Claim tab, choose the type

 


 

2

 

Predetermination / Preauthorization

 

 

Claim -F1 tab, 1 Claim tab, enter number

 


 

3

 

Primary Payer Information

 


*Patient -F2 tab, 2 Insured tab, Payers tab, enter Payer 1 by 'New Payer' or 'Find Payer' button

 


*Patient -F2 tab, 2 Insured tab, Payers tab, enter Payer 2 by 'New Payer' or 'Find Payer' button




 


 

4

 

Other Dental or Medical Coverage?

 

 

Automatically completed based on box 2 completion

 


 

5

 

Other Subscriber Name

 

 

*Patient -F2 tab, 2 Insured tab, enter Last Name, First, MI

 

or

*Patient -F2 tab, 3 Other Insured tab, enter Last Name, First, MI

 


 

6

 

Other Date of Birth

 

 

Patient -F2 tab, 2 Insured tab, enter Birthdate


Patient -F2 tab, 3 Other Insured tab, enter Birthdate




7

 

Other Gender

 

 

Patient -F2 tab, 2 Insured or 3 Other Insured tab, enter Sex




8

 

Other Subscriber Identifier (SSN or ID#)

 


*Patient -F2 tab, 2 Insured tab, Payers tab, enter Payer 2 MemberID #

 

or

*Patient -F2 tab, 3 Other Insured tab, enter Payer 3 MemberID #




9

 

Other Plan/Group Number

 


*Patient -F2 tab, 2 Insured tab, Payers tab, enter Payer 2 Group #

 

or

*Patient -F2 tab, 3 Other Insured tab, enter Payer 3 Group #




10

 

Relationship to Primary Subscriber

 

 

*Patient -F2 tab, 2 Insured or 3 Other Insured tab, enter 'Patient relationship to the other insured?'

 

11

 

Other Carrier Name and Address

 

 

*Patient -F2 tab, 3 Other Insured tab, enter Payer 3 by 'New Payer' or 'Find Payer' button




12

 

Primary Subscriber Name and Address

 


Patient -F2 tab, 2 Insured tab, enter Last Name, First, MI

 

 

Patient -F2 tab, 2 Insured tab, enter Address, City, State, and Zipcode



 

13

 

Primary Subscriber Date of Birth

 

 

Patient -F2 tab, 2 Insured tab, enter Birthdate




14

 

Primary Subscriber Gender

 

 

Patient -F2 tab, 2 Insured tab, enter Sex




15

 

Primary Subscriber Identifier (SSN or ID#)

 

 

*Patient -F2 tab, 2 Insured tab, Payers tab, enter Payer 1 MemberID #




16

 

Primary Plan/Group Number

 

 

*Patient -F2 tab, 2 Insured tab, Payers tab, enter Payer 1 Group #




17

 

Primary Subscriber Employer Name

 

 

*Patient -F2 tab, 2 Insured tab, Employer tab, enter Employer Name




18

 

Patient Relationship to Primary Subscriber

 

 

*Patient -F2 tab, 2 Insured tab, enter 'Patient relationship to the insured?'




19

 

Patient Student Status

 

 

Patient -F2 tab, 1 Patient tab, select student school status




20

 

Patient Name and Address

 


Patient -F2 tab, 1 Patient tab, enter Last Name, First, MI

 

 

Patient -F2 tab, 1 Patient tab, enter Address, City, State, and Zipcode




21

 

Patient Date of Birth

 

 

Patient -F2 tab, 1 Patient tab, enter Birthdate




22

 

Patient Gender

 

 

Patient -F2 tab, 1 Patient tab, enter Sex




23

 

Patient ID/Account #

 

 

Automatically generated by ClaimGear




24

 

Procedure Date

 

 

Claim -F1 tab, 2 Charges tab, enter Procedure Date




25

 

Area of Oral Cavity

 

 

Claim -F1 tab, 2 Charges tab, enter Area of Oral Cavity




26

 

Tooth System

 

 

Claim -F1 tab, 2 Charges tab, enter Tooth System




27

 

Tooth Number(s) or Letter(s)

 

 

Claim -F1 tab, 2 Charges tab, enter Tooth Number(s) or Letter(s)




28

 

Tooth Surface

 

 

Claim -F1 tab, 2 Charges tab, enter Tooth Surface



  

29

 

Procedure Code

 

 

Claim -F1 tab, 2 Charges tab, enter CDT




30

 

Description

 

 

Automatically generated by Procedure Code




31

 

Fee

 

 

Claim -F1 tab, 2 Charges tab, enter Total Charges




32

 

Other Fee(s)

 

 

Not required




33

 

Total Fee

 

 

Claim -F1 tab, 2 Charges tab, enter Total Charges




34

 

Missing Teeth

 

 

Claim -F1 tab, 3 Additional Info tab, enter Missing Teeth Information Box 34




35

 

Remarks

 

 

Claim -F1 tab, 3 Additional Info tab, enter Remarks Box 35




36

 

Patient/Guardian Signature

 

 

Claim -F1 tab, 3 Additional Info tab, enter Print Signature on File in Box 36




37

 

Subscriber Signature

 

 

Claim -F1 tab, 3 Additional Info tab, enter Print Signature on File in Box 37




38

 

Place of Treatment

 

 

Claim -F1 tab, 2 Charges tab, enter POS




39

 

Number of Enclosures

 

 

Claim -F1 tab, 3 Additional Info tab, enter Number of Enclosures Box 39




40

 

Is Treatment for Orthodontics?

 

 

Claim -F1 tab, 3 Additional Info tab, enter Is this an Orthodontic claim? Box 40




41

 

Date Appliance Placed

 

 

Claim -F1 tab, 3 Additional Info tab, enter Date Appliance Placed Box 41




42

 

Months of Treatment Remaining

 

 

Claim -F1 tab, 3 Additional Info tab, enter Months of Treatment Remaining Box 42




43

 

Replacement of Prosthesis?

 

 

Claim -F1 tab, 3 Additional Info tab, enter Replacement of Prosthesis Box 43




44

 

Date Prior Placement

 

 

Claim -F1 tab, 3 Additional Info tab, enter Date Prior Placement Box 44



  

45

 

Treatment Resulting from

 

 

Claim -F1 tab, 3 Additional Info tab, enter Treatment Resulting From Box 45




46

 

Date of Accident

 

 

Claim -F1 tab, 3 Additional Info tab, enter Date of Accident Box 46




47

 

Auto Accident State

 

 

Claim -F1 tab, 3 Additional Info tab, enter Auto Accident State Box 47




48

 

Billing Dentist Name and Address

 

 

Claim -F1 tab, 1 Claim tab, enter Billing Dentist




49

 

Billing Dentist NPI

 

 

Claim -F1 tab, 1 Claim tab, enter Billing Dentist




50

 

Billing Dentist License Number

 

 

Claim -F1 tab, 1 Claim tab, enter Billing Dentist




51

 

Billing Dentist SSN or TIN

 

 

Claim -F1 tab, 1 Claim tab, enter Billing Dentist




52

 

Billing Dentist Phone Number

 

 

Claim -F1 tab, 1 Claim tab, enter Billing Dentist




53

 

Treating Dentist

 

 

Claim -F1 tab, 1 Claim tab, enter Treating Dentist




54

 

Treating Dentist NPI

 

 

Claim -F1 tab, 1 Claim tab, enter Treating Dentist




55

 

Treatment Dentist License Number

 

 

Claim -F1 tab, 1 Claim tab, enter Treating Dentist




56

 

Treatment Location Address

 

 

Claim -F1 tab, 1 Claim tab, enter Treating Dentist




57

 

Treatment Location Phone Number

 

 

Claim -F1 tab, 1 Claim tab, enter Treating Dentist




58

 

Additional Provider ID

 

 

Claim -F1 tab, 1 Claim tab, enter Treating Dentist

 

NA

 

Claim - Not Found

 

 

One or more are incorrect, fix and rescore.  Patient Name (box 2), DOB (box 3), and DOS (box 24a).

 

 

See page 71 of this manual for a detailed description.

 

 

 

NA

 

Charge – Not Found

 

 

1 or more are incorrect, fix and rescore.  DOS (box 24a) and Charges (24d).

 

 

See page 70 of this manual for a detailed description.