This field is required when billing for full or partial dentures. Mark the appropriate box. Tooth Number or Letter Enter the appropriate tooth number or letter for services performed on each line item of the claim. When billing for partial dentures enter the tooth number for one of the teeth being replaced in this field, then list the remaining teeth in the description field. Procedure Code Enter the five digit code for the service performed, as well as any applicable modifiers.
Total fee Enter the total of the charges shown.
Previous Medicaid payments, and cost sharing co-insurance or copay amounts are not to be entered in this field. If the other insurance denied the claim, attach a copy of the Explanation of Benefits which denied the charges. Use Only You may enter the recipient's patient account number in this field. Maximum allowable Not required. Deductible Not required.