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
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CLAIMGEAR ADA-J400 SPECS |
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BOX DESCRIPTION OF FIELD ON FORM AND IN CLAIMGEAR |
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LOCATION OF FIELD IN CLAIMGEAR |
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1 |
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Type of Transaction |
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Claim -F1 tab, 1 Claim tab, choose the type |
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2 |
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Predetermination / Preauthorization |
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Claim -F1 tab, 1 Claim tab, enter number |
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3 |
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Primary Payer Information |
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*Patient -F2 tab, 2 Insured tab, Payers tab, enter Payer 1 by 'New Payer' or 'Find Payer' button |
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*Patient -F2 tab, 2 Insured tab, Payers tab, enter Payer 2 by 'New Payer' or 'Find Payer' button |
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4 |
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Other Dental or Medical Coverage? |
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Automatically completed based on box 2 completion |
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5 |
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Other Subscriber Name |
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*Patient -F2 tab, 2 Insured tab, enter Last Name, First, MI |
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or |
*Patient -F2 tab, 3 Other Insured tab, enter Last Name, First, MI |
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6 |
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Other Date of Birth |
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Patient -F2 tab, 2 Insured tab, enter Birthdate
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7 |
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Other Gender |
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Patient -F2 tab, 2 Insured or 3 Other Insured tab, enter Sex |
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8 |
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Other Subscriber Identifier (SSN or ID#) |
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*Patient -F2 tab, 2 Insured tab, Payers tab, enter Payer 2 MemberID # |
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or |
*Patient -F2 tab, 3 Other Insured tab, enter Payer 3 MemberID # |
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9 |
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Other Plan/Group Number |
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*Patient -F2 tab, 2 Insured tab, Payers tab, enter Payer 2 Group # |
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or |
*Patient -F2 tab, 3 Other Insured tab, enter Payer 3 Group # |
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10 |
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Relationship to Primary Subscriber |
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*Patient -F2 tab, 2 Insured or 3 Other Insured tab, enter 'Patient relationship to the other insured?' |
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11 |
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Other Carrier Name and Address |
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*Patient -F2 tab, 3 Other Insured tab, enter Payer 3 by 'New Payer' or 'Find Payer' button |
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12 |
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Primary Subscriber Name and Address |
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Patient -F2 tab, 2 Insured tab, enter Last Name, First, MI |
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Patient -F2 tab, 2 Insured tab, enter Address, City, State, and Zipcode |
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13 |
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Primary Subscriber Date of Birth |
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Patient -F2 tab, 2 Insured tab, enter Birthdate |
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14 |
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Primary Subscriber Gender |
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Patient -F2 tab, 2 Insured tab, enter Sex |
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15 |
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Primary Subscriber Identifier (SSN or ID#) |
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*Patient -F2 tab, 2 Insured tab, Payers tab, enter Payer 1 MemberID # |
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16 |
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Primary Plan/Group Number |
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*Patient -F2 tab, 2 Insured tab, Payers tab, enter Payer 1 Group # |
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17 |
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Primary Subscriber Employer Name |
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*Patient -F2 tab, 2 Insured tab, Employer tab, enter Employer Name |
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18 |
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Patient Relationship to Primary Subscriber |
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*Patient -F2 tab, 2 Insured tab, enter 'Patient relationship to the insured?' |
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19 |
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Patient Student Status |
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Patient -F2 tab, 1 Patient tab, select student school status |
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20 |
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Patient Name and Address |
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Patient -F2 tab, 1 Patient tab, enter Last Name, First, MI |
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Patient -F2 tab, 1 Patient tab, enter Address, City, State, and Zipcode |
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21 |
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Patient Date of Birth |
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Patient -F2 tab, 1 Patient tab, enter Birthdate |
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22 |
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Patient Gender |
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Patient -F2 tab, 1 Patient tab, enter Sex |
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23 |
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Patient ID/Account # |
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Automatically generated by ClaimGear |
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24 |
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Procedure Date |
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Claim -F1 tab, 2 Charges tab, enter Procedure Date |
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25 |
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Area of Oral Cavity |
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Claim -F1 tab, 2 Charges tab, enter Area of Oral Cavity |
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26 |
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Tooth System |
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Claim -F1 tab, 2 Charges tab, enter Tooth System |
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27 |
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Tooth Number(s) or Letter(s) |
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Claim -F1 tab, 2 Charges tab, enter Tooth Number(s) or Letter(s) |
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28 |
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Tooth Surface |
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Claim -F1 tab, 2 Charges tab, enter Tooth Surface |
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29 |
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Procedure Code |
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Claim -F1 tab, 2 Charges tab, enter CDT |
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30 |
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Description |
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Automatically generated by Procedure Code |
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31 |
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Fee |
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Claim -F1 tab, 2 Charges tab, enter Total Charges |
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32 |
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Other Fee(s) |
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Not required |
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33 |
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Total Fee |
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Claim -F1 tab, 2 Charges tab, enter Total Charges |
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34 |
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Missing Teeth |
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Claim -F1 tab, 3 Additional Info tab, enter Missing Teeth Information Box 34 |
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35 |
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Remarks |
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Claim -F1 tab, 3 Additional Info tab, enter Remarks Box 35 |
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36 |
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Patient/Guardian Signature |
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Claim -F1 tab, 3 Additional Info tab, enter Print Signature on File in Box 36 |
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37 |
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Subscriber Signature |
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Claim -F1 tab, 3 Additional Info tab, enter Print Signature on File in Box 37 |
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38 |
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Place of Treatment |
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Claim -F1 tab, 2 Charges tab, enter POS |
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39 |
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Number of Enclosures |
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Claim -F1 tab, 3 Additional Info tab, enter Number of Enclosures Box 39 |
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40 |
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Is Treatment for Orthodontics? |
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Claim -F1 tab, 3 Additional Info tab, enter Is this an Orthodontic claim? Box 40 |
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41 |
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Date Appliance Placed |
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Claim -F1 tab, 3 Additional Info tab, enter Date Appliance Placed Box 41 |
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42 |
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Months of Treatment Remaining |
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Claim -F1 tab, 3 Additional Info tab, enter Months of Treatment Remaining Box 42 |
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43 |
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Replacement of Prosthesis? |
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Claim -F1 tab, 3 Additional Info tab, enter Replacement of Prosthesis Box 43 |
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44 |
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Date Prior Placement |
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Claim -F1 tab, 3 Additional Info tab, enter Date Prior Placement Box 44 |
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45 |
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Treatment Resulting from |
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Claim -F1 tab, 3 Additional Info tab, enter Treatment Resulting From Box 45 |
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46 |
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Date of Accident |
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Claim -F1 tab, 3 Additional Info tab, enter Date of Accident Box 46 |
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47 |
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Auto Accident State |
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Claim -F1 tab, 3 Additional Info tab, enter Auto Accident State Box 47 |
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48 |
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Billing Dentist Name and Address |
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Claim -F1 tab, 1 Claim tab, enter Billing Dentist |
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49 |
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Billing Dentist NPI |
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Claim -F1 tab, 1 Claim tab, enter Billing Dentist |
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50 |
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Billing Dentist License Number |
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Claim -F1 tab, 1 Claim tab, enter Billing Dentist |
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51 |
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Billing Dentist SSN or TIN |
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Claim -F1 tab, 1 Claim tab, enter Billing Dentist |
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52 |
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Billing Dentist Phone Number |
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Claim -F1 tab, 1 Claim tab, enter Billing Dentist |
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53 |
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Treating Dentist |
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Claim -F1 tab, 1 Claim tab, enter Treating Dentist |
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54 |
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Treating Dentist NPI |
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Claim -F1 tab, 1 Claim tab, enter Treating Dentist |
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55 |
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Treatment Dentist License Number |
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Claim -F1 tab, 1 Claim tab, enter Treating Dentist |
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56 |
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Treatment Location Address |
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Claim -F1 tab, 1 Claim tab, enter Treating Dentist |
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57 |
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Treatment Location Phone Number |
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Claim -F1 tab, 1 Claim tab, enter Treating Dentist |
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58 |
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Additional Provider ID |
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Claim -F1 tab, 1 Claim tab, enter Treating Dentist |
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NA |
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Claim - Not Found |
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One or more are incorrect, fix and rescore. Patient Name (box 2), DOB (box 3), and DOS (box 24a). |
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See page 71 of this manual for a detailed description. |
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NA |
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Charge – Not Found |
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1 or more are incorrect, fix and rescore. DOS (box 24a) and Charges (24d). |
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See page 70 of this manual for a detailed description. |
