Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 53 - Dental Care Services, Reimbursement Schedule and Billing Instructions › Section I-5313 - Billing Instructions

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				  American Dental Association (ADA) claim form is to be used for billing services
				  provided to workers' compensation employer claimants. Do not use any other
				  form.
B. Partial bills should not
				  be filed by the provider or the claimant. An invoice for the full amount must
				  be filed by one of the two parties. If the claimant pays for medical or other
				  services which are determined to be compensable expenses, it is his
				  responsibility to file the ADA dental claim form, with the workers'
				  compensation carrier/self-insured employer to receive reimbursement.
C. This is not the case if the provider
				  agrees to file for the claimant; the carrier will pay directly to the provider
				  and the provider must refund any partial payments made by the claimant directly
				  to the claimant.
D. Please read the
				  instructions carefully before completing the form. Failure to provide the
				  information requested in a readable form will result in delay of
				  payment.
E. A sample ADA dental
				  claim form and detailed instructions for the proper completion of the form
				  follows.
Sample ADA Form
Click Here To View
					 Image
F.
				  Item-by-Item Instructions for Completion of the ADA Dental Claim Form. This
				  Section is intended to serve as an instructional guide for completing the ADA
				  dental insurance claim form. All applicable information should be completed in
				  full.
Dentist's Pretreatment Estimate, or
								Statement of Actual Services
: Check the appropriate box to indicate if
								the form is being used for an estimate and authorization, or if the form
								represents a statement of actual services.
Carrier Name and Address
: Enter the
								name and address of the carrier where the claim is to be sent.
Item 1
Patient's Name
-enter the patient's
								first name, middle initial and last name.
Item 2
Relationship to Employee
-"Self" is
								the claimant. (Workers' compensation claims should always show "self".) Put an
								"X" in the appropriate box.
Item 3
Sex
-put an "X" in the appropriate
								box; male or female.
Item 4
Patient Birthdate
-enter the
								patient's date of birth, month, day and year.
Item 5
If Full-Time Student
-leave blank.
Item 6
Employee/Subscriber Name and Address
-same as patient's name and address.
Item 7
Employee/Subscriber Social Security or I.D.
								Number
-if the patient has other insurance, show the insured's policy
								number.
Item 8
Employee/Subscriber Birthday
-same as
								patient's birthday.
Item 9
Employer (Company name and address)
-enter the employer's (company's) name and address.
Item 10
Group Number
-if the patient has
								other insurance, show the insured's group number.
Item 11
Is Patient Covered By Another Dental Plan?
Leave blank.
Item 12a
Name and Address of Carrier
-Leave
								blank.
Item 12b
Group Number
-Leave blank.
Item 13
Name and Address of Other Employer(s)
Leave blank.
Item 14a
Employee/Subscriber Name (If Different Than
								Patient's)
Leave blank.
Item 14b
Employee/Subscriber Social Security Or I.D.
								Number
-Leave blank.
Item 14c
Employee/Subscriber Birth Date
-Leave
								blank.
Item 15
Relationship to Patient
-Leave blank.
Patient Signature
-Have the patient
								or his authorized representative sign and date this block unless the signature
								is on file. If the patient's representative signs, the relationship to the
								patient must be indicated. The patient's signature authorizes release of
								medical information necessary to process the claim. It also authorizes payment
								of benefits to the physician or supplier.
Signature by Mark
-Where an
								illiterate or physically handicapped person signs by mark (X), a witness must
								enter his/her name and address next to the mark.
Insured Person's Signature Block
-The
								signature in this block authorizes payment to the physician or supplier.
Item 16
Name of Billing Dentist or Entity
-Enter the individual dentist's name or the name of the group/practice
								corporation responsible for the billing. This may differ from the actual
								treating dentist's name. This is the name that should appear on any payments or
								correspondence that will be remitted to the billing dentist.
Item 17
Address Where Payment Should Be Remitted
-Enter the address of the billing dentist or entity in Item 16.
Item 18
Dentist's Social Security Number or T.I.N.
-Show your physician/supplier federal tax I.D. (Employer Identification
								Number) or Social Security number.
Item 19
Dentist's License Number
-Enter the
								license number of the billing dentist. This may differ from that of the
								treating dentist, which appears in the dentist's signature block at the bottom
								of the form.
Item 20
Dentist's Phone Number
-Enter the
								dentist's area code and phone number.
Item 21
First Visit Date Current Series
-Enter the date of the first visit in the current series of treatment.
Item 22
Place of Treatment
-Enter the
								appropriate place of service code from the list provided.
Place of Service Codes and Definitions
Codes
Definitions
00-10
Unassigned
11
Office
-Location, other than a
								hospital, skilled nursing facility (SNF), military treatment facility.
								Community health facility, state or local public health clinics or intermediate
								care facility (ICF), where the health professional routinely provides health
								examinations, diagnosis and treatment of illness or injury on an ambulatory
								basis.
12
Patient's Home
-Location, other than
								a hospital or other facility, where the patient receives care in a private
								residence.
13-20
Unassigned
21
Inpatient Hospital
-A facility, other
								than psychiatric, which primarily provides diagnostic therapeutic (both
								surgical and nonsurgical) and rehabilitation services, or under the supervision
								of physicians to patients admitted for a variety of medical conditions.
22
Outpatient Hospital
-A portion of a
								hospital which provides diagnostic, therapeutic (both surgical or nonsurgical)
								and rehabilitation services to sick or injured persons who do not require
								hospitalization or institutionalization.
23
Emergency Room-Hospital
-A portion of
								a hospital where emergency diagnosis and treatment of illness or injury is
								provided.
24
Ambulatory Surgical Center
-A
								freestanding facility, other than a physician's office, where surgical and
								diagnostic services are provided on an ambulatory basis.
25
Birthing Center
-A facility, other
								than a hospital's maternity facility or a physician's office, which provides a
								setting for labor, delivery and immediate post-partum care as well as immediate
								care of newborn infants.
26
Military Treatment Facility
-A
								medical facility operated by one or more of the uniformed services. Military
								treatment facility (MTF) also refers to certain former U.S. Public Health
								Services (USPHS) facilities now designated as uniformed service treatment
								facilities (USTF).
27-30
Unassigned
31
Skilled Nursing Facility
-A facility
								which primarily provides inpatient skilled nursing care and related services to
								patients who require medical, nursing or rehabilitative services but does not
								provide the level of care or treatment available in a hospital.
32
Nursing Facility
-A facility which
								primarily provides to residents skilled nursing care and related services for
								the rehabilitation of injured, disabled or sick persons, or, on a regular
								basis, health related care services above the level of custodial care to other
								than mentally retarded individuals.
33
Custodial Care Facility
-A facility
								which provides room, board and other personal assistance services, generally on
								a long-term basis, and which does not include a medical component.
34
Hospice
-A facility, other than a
								patient's home, in which palliative and supportive care for terminally ill
								patients and their families are provided.
35-40
Unassigned
41
Ambulance-Land
-A land vehicle
								specifically designed, equipped and staffed for lifesaving and transporting the
								sick or injured.
42
Ambulance-Air or Water
-An air or
								water vehicle specifically designed, equipped and staffed for lifesaving and
								transporting the sick or injured.
43-50
Unassigned
51
Inpatient Psychiatric Facility
-A
								facility that provides inpatient psychiatric services for the diagnosis and
								treatment of mental illness on a 24-hour basis, by or under the supervision of
								a physician.
52
Psychiatric Facility Partial Hospitalization
-A facility for the diagnosis and treatment of mental illness that
								provides a planned therapeutic program for patients who do not require
								full-time hospitalization, but who need broader programs than are possible from
								outpatient visits in a hospital-based or hospital-affiliated facility.
53
Community Mental Health Center
-A
								facility that provides comprehensive mental health services on an ambulatory
								basis primarily to individuals residing or employed in a defined area.
54
Intermediate Care Facility/Mentally Retarded
-A facility which primarily provides health-related care and services
								above the level of custodial care to mentally retarded individuals but does not
								provide the level of care or treatment available in a hospital or SNF.
55
Residential Substance Abuse Treatment
								Facility
-A facility which provides treatment for substance (alcohol and
								drug) abuse to live-in residents who do not require acute medical care.
								Services include individual and group therapy and counseling, laboratory tests,
								drugs and supplies, psychological testing, and room and board.
56
Psychiatric Residential Treatment Center
57-60
Unassigned
61
Comprehensive Inpatient Rehabilitation
								Facility
-A facility that provides comprehensive rehabilitation services
								under the supervision of a physician to inpatients with physical disabilities.
								Services include physical therapy, occupational therapy, speech pathology,
								social or psychological services, and orthotics and prosthetics services.
62
Comprehensive Outpatient Rehabilitation
								Facility
-A facility that provides comprehensive rehabilitation services
								under the supervision of a physician to outpatients with physical disabilities.
								Services include physical therapy, occupational therapy, and speech pathology
								services.
63-64
Unassigned
65
End Stage Renal Disease Treatment Facility
-A facility other than a hospital, which provides dialysis treatment,
								maintenance and/or training to patients or care givers on an ambulatory or
								home-care basis.
66-70
Unassigned
71
State or Local Public Health Clinic
-A facility maintained by either state or local health departments that
								provides ambulatory primary medical care under the general direction of a
								physician.
72
Rural Health Clinic
-A certified
								facility which is located in a rural medically underserved area that provides
								ambulatory primary medical care under the general direction of a physician.
73-80
Unassigned
81
Independent Laboratory
-A laboratory
								certified to perform diagnostic and/or clinical tests independent of an
								institution or a physician's office.
82-98
Unassigned
99
Other Unlisted Facility
-Other
								service facilities not identified above.
Item 23
Radiographs or Models Enclosed
-Indicate whether diagnostic materials were submitted.
Item 24
Is Treatment Result of Occupational Illness
								or Injury?
Check yes or no to indicate whether employment related.
Item 25
Is Treatment Result of Auto Accident?
Check yes or no to indicate whether injury is related to auto accident.
Item 26
Other Accident
-Check yes or no to
								indicate accident other than employment or auto related.
Item 27
If Prosthesis, Is This The Initial
								Placement?
-Check yes or no.
Item 28
Date of Prior Placement?
Enter the
								date of prior placement if applicable.
Item 29
Is Treatment for Orthodontics?
Check
								appropriate box.
Item 30
Examination and Treatment Plan
-Enter
								the examination and/or plan of treatment. List in order from Tooth #1 through
								Tooth #32 using the charting system shown.
Item 31
Remarks for Unusual Services
-Enter
								any information which may be helpful in determining the most appropriate
								benefit for the treatment. If space is inadequate, utilize unused portion of
								#30, or attach a separate sheet.
Dentist's Signature Block
-Must
								include treating dentist's signature and license number.
Payment Itemization
-The spaces under
								"Total Fee Charged" will be completed by the carrier.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 23:1034.2.