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Denti-Cal 

Denti-Cal website: http://www.denti-cal.ca.gov/WSI/Prov.jsp?fname=EDI

To submit claims to Denti-cal, you can print a paper Claim Form, or submit an E-claim.  If printing forms, here are the downloads for the 2008 DentiCal claimform: 
DC-217.gif - background image for all versions.
Dentical-DC-217.xml - use for versions 12.3.2 and earlier.
Dentical-DC-217_v12_3_3.xml - use for versions 12.3.3 and greater.

CDT Codes (1/14/2014):  Providers should continue to submit CDT 11-12 codes until further notice. 2103 or 2014 CDT codes will not be accepted.  See http://www.denti-cal.ca.gov/provsrvcs/bulletins/Volume_30_Number_1.pdf.  Also see Troubleshooting below.

Submitting Claims
Most Denti-Cal users submit claims to a Clearinghouse, which then submits to Denti-Cal. Open Dental users have submitted claims to Denti-Cal in this manner for many years.

Larger offices have always wanted to submit directly to Denti-Cal, because there is a fee per claim when using a clearinghouse. The Open Dental X12 file format is certified by Denti-Cal, however each dental office that wishes to submit directly must also go through their own certification testing with Denti-Cal. If you wish to submit E-claims directly to Denti-Cal, you must use Open Dental version 13.1.43 or later. During the testing phase, you can still use your existing clearinghouse (e.g. ClaimConnect) to submit claims.

Follow the steps below to begin the testing certification process.

Step 1: Fill out the Provider Service Office Electronic Data Interchange OSF
Before testing can begin, please notify Denti-Cal's EDI Support so that approval can be obtained from the State.  Providers currently enrolled to submit electronically must fill out a Provider Service Office Electronic Data Interchange Option Selection Form (OSF) to update options to that of a direct submitter.  The most recent OSF can be found by visiting the Denti-Cal website at http://www.denti-cal.ca.gov/WSI/Prov.jsp?fname=EDI, or by calling Denti-Cal at (916) 853-7373 and asking to speak with EDI Support. On the OSF, there is a section named "RETURN OUTPUT OPTIONS when available (standard options are shaded)", which must be filled out as follows:

Submit all the OSF forms to Denti-Cal. Once testing is approved, Denti-Cal EDI Support will provide a Remote ID, username, and password.  This is required to setup the clearinghouse.

If a Service Office Number must be sent in order to supplement an NPI, then enter that number at the bottom of the Provider Edit window, with a type of SiteNumber. That number will be sent in loop 2010BB with a qualifier of LU.

Step 2 - Setup the Denti-Cal Clearinghouse
Set up the Denti-Cal Clearinghouse like the screenshot below, except use the Remote ID, username, and password supplied by Denti-Cal in Step 1.

Step 3 - Submit Test Cases for Certification
For the test cases below, make sure to use data from real patients and real insurance plans to make testing easier. The claims used for testing should be fake claims, because they will not be adjudicated.

Manually enter two test patients into a blank Open Dental database as follows:
Patient 1: One Denti-Cal insurance plan with real subscriber name and subscriber ID. No other insurance plans.
Patient 2: Two insurance plans. The primary insurance plan must be the Denti-Cal plan with a real subscriber name and real subscriber ID. For the secondary plan, create a fake plan with subscriber ID 123456789 for any carrier other than Denti-Cal.

Create the following fake claims for certification testing. Once all claims are created, all test cases can be sent in a single test batch.

Share of Cost with Xray attachment
- Select Patient 1.
- Create a claim with one procedure: a D0270 with a $100 fee. Set the deductible for the procedure to $5.
- In the Edit Claim window, under the General tab, type "1" in the Radiographs textbox.

Multiple Dates of Service and Multiple Providers
- Select Patient 1.
- Create a claim with two procedures: a D0120 with fee $60 and a D1351 with fee $130.
- Set the date for the D0120 to today's date, and set the date for the D1351 to yesterday's date.
- Change the treating provider on the D1351 so it is different than the treating provider for the D0120 (based on NPI).

Correction (Adjustment)
- Select Patient 1.
- Create a claim with one procedure: a D1110 with fee $40.
- In the Edit Claim window, under the Misc tab, set the Correction Type to Replacement and the Original Reference Num to "123456789".

Preauthorization (TAR)
- Select Patient 2.
- Treatment plan a D0150 with fee $20.
- In the Treatment Plan module, select the D0150 and click the PreAuthorization button to create a new Preauthorization claim.
- In the Edit Claim window, under the Misc tab, set the Prior Authorization (rare) to "12345678".

Secondary Insurance with Other Attachments
- Select Patient 2.
- Create a primary claim with one procedure: a D6750 with a $500 fee.
- In the Edit Claim window, under the General tab, set the Attachment ID Number to "NEA#1234567".

To send the test batch, in the Manage module, click Send Claims.  Click the Send E-Claims dropdown, then select Denti-Cal.

Step 4 - Notify Denti-Cal and Wait for Test Verification
Notify Denti-Cal's EDI Support (denti-caledi@delta.org) that you intend to submit a batch of test claims. Following review, EDI Support will let you know if there is anything wrong with the batch, or if additional test claims are needed. EDI Support will notify you when the batch meets their test requirements, then they will notify you when you have been cleared for live claims in the production environment.

Preauthorization DCN
DentiCal assigns a Document Control Number (DCN) to the original preauthorization submitted.  When the claim associated with a preauth is submitted, DentiCal requires that the DCN be in 2300 REF(G1).  This field is normally where we put the preauthorization string that the user can enter in the Claim Edit window.  So the user has control of this field.  If you can figure out what the DCN is by looking at the approval that was sent by DentiCal, then you can put that number into the PreAuth Number field in the Edit Claim window.

Troubleshooting
Problem: I updated my CDT Codes to 2013 (or 2014) and cannot find D1203 or D1204.
Solution: One 2013 CDT change was the addition of D1208 to replace D1203 and D1204.  As part of the Open Dental update, D1203 and D1204 were moved to the Obsolete category in the Procedure Code List, which may be hidden.  To unhide these codes for use, simply check the Show Hidden box on the Procedure Codes window.  You can also move the codes to a different category if desired.

 

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