In the Claim - General tab are fields for prosthetics, orthodontic work, claim referrals, and claim note.
In the Claim Edit window, click the General tab.
Crown, Bridge or Denture: For bridges, dentures, and partials, Missing/Primary Teeth must have been correctly entered in the Chart module. If Replacement is selected, a Prior Date is required. This information only shows on printed claims and is not sent electronically. To send this information electronically, enter on the Procedure Info window (Prosthesis Replacement, Original Date).
Place of Service: The service location. Defaults to the Place of Service on the last procedure in the claim (as set on the Procedure - Misc Tab). If Public Health is turned on in Show Features, the default is based on the site's default place of service (Site List).
- Sent in dental 5010 e-claims only.
- Changing place of service here will change the Place of Service on all procedures on the claim.
- Usually set to Office. Exceptions: certain procedures to specific insurance carriers (e.g., Medicaid), sometimes when using clinics.
Accident: Used to indicate that dental treatment was needed as the result of an accident.
- Accident Related: The type of accident. Shows on printed Claim Forms in the following fields (depending on the value chosen): IsOccupational, IsNotOccupational, IsAutoAccident, IsNotAutoAccident, IsOtherAccident, IsNotOtherAccident, IsNotAccident, IsAccident, MedAccidentCode.
- Accident Date: Shows on printed claims and e-claims. On printed claims, shows in the AccidentDate field.
- Accident State: Shows on printed claims in the AccidentST field and on e-claims for auto accidents.
Ortho: Only used for ortho claims.
- Is for Ortho: Affects the IsOrtho and IsNotOrtho fields on printed claims. If the checkbox is marked, then Months Remaining is reported on e-claims (in Canada the ortho flag is sent electronically instead). Checked automatically if Mark claims as Ortho if they have ortho procedures is enabled in Ortho Setup and the claim includes an orthodontic procedure.
- Date of Placement: Shows on printed claims and dental e-claims. On printed claims, shows in the DateOrthoPlaced field. If Use the first ortho procedure date as Date of Placement is checked in Ortho Setup, the date of the first orthodontic procedure on the claim auto-populates the field.
- Months Total: Enter total months sent in 5010 e-claims.
- Months Remaining: Shows on printed claims in the MonthsOrthoRemaining field if the value is greater than zero.
Claim Referral: Only enter a referring provider and referral number if it is required by your insurance carrier.
- Referring Provider: Click select to attach a referring provider from an existing list, or add a new Referral. Click None to clear the field. Click Edit to enter notes or change information about the selected provider.
- Referral Number: Provided by your insurance carrier. Do not put NPI numbers here; NPI numbers must be entered on the Edit Referral window. If an NPI number is missing, it will cause a claim rejection.
Note: For a referring provider on a claim, the Not Person checkbox must be unchecked and the Is Doctor checkbox checked. See Referral List
. The information will not send otherwise.
Claim Note: A claim level note that shows on printed claims and e-claims. The claim note and attachment ID Number together are limited to 400 characters using the 5010 claim format, or 80 characters using the 4010. When printed using the ADA 2019 form, only approximately the first 253 characters will be visible. If a procedure in the claim has a default claim note, it will automatically copy to this field when the claim is created. If multiple procedures have default claim notes, each note will added. Enter a procedure's default claim notes on the Procedure Code.
Note: There is also a procedure-level note, which only goes out on e-claims and medical HCFA 1500 Claim Form
. There is no place on a printed claim ADA form to put a procedure-level note. Add procedure level note in the Procedure Info