Electronic Claim Submission via Clearinghouse
DentaQuest works directly with Emdeon (1-888-255-7293), Tesia 1-800-724-7240, EDI Health Group 1-800-576-6412, Secure EDI 1-877-466-9656 and Mercury Data Exchange 1-866-633-1090, for claim submissions to DentaQuest.
You can contact your software vendor and make certain that they have DentaQuest listed as the payer and claim mailing address on your electronic claim. Your software vendor will be able to provide you with any information you may need to ensure that submitted claims are forwarded to DentaQuest. DentaQuest’s Payor ID is CX014.
27.5 HIPAA Compliant 837DFile
For Providers who are unable to submit electronically via the Internet or a clearinghouse, DentaQuest will work directly with the Provider to receive their claims electronically via a HIPAA compliant 837D or 837P file from the Provider’s practice management system. 27.6 NPI Requirements for Submission of Electronic Claims
In accordance with the HIPAA guidelines, DentaQuest has adopted the following NPI standards in order to simplify the submission of claims from all of our providers, conform to industry required standards and increase the accuracy and efficiency of claims administered by DentaQuest.
• Providers must register for the appropriate NPI classification at the following website https://nppes.cms.hhs.gov/NPPES/Welcome.do and provide this information to DentaQuest in its entirety.
• All providers must register for an Individual NPI. You may also be required to register for a group NPI (or as part of a group) dependant upon your designation.
• When submitting claims to DentaQuest you must submit all forms of NPI properly and in their entirety for claims to be accepted and processed accurately. If you registered as part of a group, your claims must be submitted with both the Group and Individual NPI’s. These numbers are not interchangeable and could cause your claims to be returned to you as non-compliant.
• If you are presently submitting claims to DentaQuest through a clearinghouse or through a direct integration you need to review your integration to assure that it is in compliance with the revised HIPAA compliant 837D format. This information can be found on the 837D Companion Guide located on the Provider Web Portal.
27.7 Paper Claim Submission
• Claims must be submitted on 2018, 2019, or later ADA approved claim forms.
• Member name, identification number, and date of birth must be listed on all claims submitted. If the Member identification number is missing or miscoded on the claim form, the patient cannot be identified. This could result in the claim being returned to the submitting Provider office, causing a delay in payment.
• The paper claim must contain an acceptable provider signature.
• The Provider and office location information must be clearly identified on the claim. Frequently, if only the dentist signature is used for identification, the dentist’s name cannot be clearly identified. Please include either a typed dentist (practice) name or the DentaQuest Provider identificationnumber.
• The paper claim form must contain a valid provider NPI (National Provider Identification) number. In the event of not having this box on the claim form, the NPI must still be included on the form. The ADA claim form only supplies 2 fields to enter NPI. On paper claims, the Type 2 NPI identifies the payee, and may be submitted in conjunction with a Type 1 NPI to identify the dentist who provided the treatment. For example, on a standard ADA Dental Claim Form, the treating dentist’s NPI is entered in field 54 and the billing entity’s NPI is entered in field49.
• The date of service must be provided on the claim form for each service line submitted.
• Approved ADA dental codes as published in the current CDT book or as defined in this
manual must be used to define all services.
• List all quadrants, tooth numbers and surfaces for dental codes that necessitate identification (extractions, root canals, amalgams and resin fillings). Missing tooth and surface identification codes can result in the delay or denial of claim payment.
Affix the proper postage when mailing bulk documentation. DentaQuest does not accept postage due mail. This mail will be returned to the sender and will result in delay of payment.
Claims should be mailed to the following address:
DentaQuest- Claims PO Box 2906
Milwaukee, WI 53201-2906
For questions, providers may contact DentaQuest Provider Services at 844.776.8740.
27.8 Coordination of Benefits (COB)
Medicaid is the payer of last resort. Providers should ask Members if they have other dental insurance coverage at the time of their appointment. When Medicaid is the secondary insurance carrier, a copy of the primary carrier's Explanation of Benefits (EOB) must be submitted with the claim. For electronic claim submissions, the payment made by the primary carrier must be indicated in the appropriate COB field. When a primary carrier's payment meets or exceeds the Medicaid fee schedule, DentaQuest will consider the claim paid in full and no further payment will be made on the claim.
27.9 Member Billing Restrictions
Providers may not bill Members directly for Covered Services. DentaQuest reimburses only those services that are medically necessary and a Covered benefit in the respective program the Member is enrolled in. Medicaid Members do not have co-payments.
Member Acknowledgement Statement
A Provider may bill a Member for a claim denied as not being medically necessary or not a part of a Covered service if both of the following conditions are met:
• A specific service or item is provided at the request of the client
• If the Provider obtains a written waiver from the Member prior to rendering such
service. The Member Acknowledgment Statement reads as follows:
“I understand that, in the opinion of (Provider’s name), the services or items that I have requested to be provided to me on (dates of service) may not be covered under the Texas Medicaid Assistance Program as being reasonable and medically necessary for my care. I understand that DentaQuest through its contract with Superior and HHSC determines the medical necessity of the services or items that I request and receive. I also understand that I am responsible for payment of the services or items I request and receive if these services or items are determined not to be reasonable and medically necessary for my care.”
27.10 Private Pay Form (Non-Covered Services Disclosure Form)
There are instances when the dentist may bill the Member. For example, if the Provider accepts the Member as a private pay patient and informs the Member at the time of service that the Member will be responsible for payment for all services. In this situation, it is recommended that the Provider use a Private Pay Form. It is suggested that the Provider use the Member Acknowledgement Statement listed above as the Private Pay Form, or use the DentaQuest Non-Covered Services Disclosure Form. Without written, signed documentation that the Member has been properly notified of their private pay status, the Provider could not ask for payment from a Member.