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| Claim ID | Patient ID | Enclosures | Orthodontics Treatment | Date Appliance Placed | Prosthesis Replacement | Date Prior Placement | Accident Date | Remarks | Patient Signature Date | Subscriber Signature Date | Treating Dentist Signature Date | Statement of Actual Services | Request for Preauthorization | EPSDT Title XIX | Auto Accident State | Billing Dentist NPI | Treating Dentist NPI | Occupational Illness/Injury | Other Fee | Diagnosis Code List Qualifier | Preauthorization Number | Months of Treatment | Treatment For | Place of Treatment | Patient Signature | Subscriber Signature | Treating Dentist Signature |
|---|
| Claim ID | Diagnosis Code | Primary Diagnosis |
|---|
| First Name | Middle Initial | Last Name | Suffix | City | State | ZIP Code | Specialty Code | NPI | Street Address | License Number | Additional Provider ID | TIN | Phone Number |
|---|
| Diagnosis Code | Diagnosis Description |
|---|
| Insurance Plan ID | Plan Name | City | State | ZIP Code | Street Address |
|---|
| Claim ID | Tooth ID |
|---|
| Oral Cavity Area Description | Oral Cavity Area Code |
|---|---|
| Entire oral cavity | 00 |
| Maxillary arch | 01 |
| Mandibular arch | 02 |
| Upper right quadrant | 10 |
| Upper left quadrant | 20 |
| Lower left quadrant | 30 |
| Lower right quadrant | 40 |
| Patient ID | Birth Date | First Name | Middle Initial | Last Name | Suffix | City | State | ZIP Code | Gender | Account Number | Street Address |
|---|
| Place of Service Description | Place of Service Code |
|---|---|
| Office | 11 |
| Home | 12 |
| Inpatient Hospital | 21 |
| Outpatient Hospital | 22 |
| Skilled Nursing Facility | 31 |
| Nursing Facility | 32 |
| Claim ID | Subscriber ID | Primary Subscriber | Patient Subscriber Relationship |
|---|
| Procedure Code | Procedure Description |
|---|
| Service ID | Claim ID | Procedure Date | Quantity | Fee | Area of Oral Cavity | Tooth Surface | Tooth System | Diagnostic Code Pointer | Description | Procedure Code |
|---|
| Service ID | Tooth ID |
|---|
| Specialty Description | Specialty Code |
|---|---|
| Dentist | 12230000X |
| General Practice | 1223G0001X |
| Dental Public Health | 1223D0001X |
| Endodontics | 1223E0200X |
| Orthodontics | 1223X0400X |
| Pediatric Dentistry | 1223P0221X |
| Periodontics | 1223P0300X |
| Prosthodontics | 1223P0700X |
| Oral & Maxillofacial Pathology | 1223P0106X |
| Oral & Maxillofacial Radiology | 1223D0008X |
| Oral & Maxillofacial Surgery | 1223S0112X |
| Subscriber ID | Birth Date | First Name | Middle Initial | Last Name | Suffix | City | State | ZIP Code | Gender | Coverage Type | Group Number | Street Address | Employer Name | Insurance Plan ID |
|---|
| Tooth Number | Tooth Letter | Tooth ID | Tooth Description |
|---|
| Tooth Surface Description | Tooth Surface Code |
|---|---|
| Buccal | B |
| Distal | D |
| Facial | F |
| Incisal | I |
| Lingual | L |
| Mesial | M |
| Occlusal | O |