E-Claims Complexities 

The information sent on e-claims is complex and is different in many cases than the information sent on paper claims.

Prosthesis
Initial or Replacement. On e-claims, there is no claim-level field for this information. The information is instead attached directly to each procedure. The claim-level field that is shown in the Claim Edit window will be completely ignored on e-claims.  All e-claims are validated before being allowed to be sent.  If the procedure-level prosthesis information is missing in the Procedure Edit window for any prosthesis procedure, the e-claim cannot be sent.  For paper claims, the opposite is true: procedure-level prosthesis information is ignored and all that goes out on the claim is the claim-level information.

Claim Note
In the Claim Edit window, there is a box for a Claim Note.  This note goes out on both e-claims and paper claims.  There is also a Procedure-level note for e-claims.  On e-claims, both kinds of notes go out.

CLM01
The specifications state,
"The number that the submitter transmits in this position is echoed back to the submitter in the 835 transaction. The two recommended identifiers are either the Patient Account Number or the Claim Number in the billing submitter’s patient management system. The developers of this implementation guide strongly recommend that submitters use completely unique numbers for this field for each individual claim."
Prior to version 7.0, the internal OD ClaimNum was used because it is unique for each claim.  But it turns out that the PatNum is much more useful because some clearinghouses display this number in their reports.  And if the number is PatNum, then it becomes very easy for the office to look up the patient being referenced.  We currently use PatNum/ClaimNum, for example 3246/5412.

Emdeon is known to add their own unique string to the end of whatever number is sent so that the number will be unique.  In the case of a preauthorization followed by a claim, DentiCal requires that the number in this field be identical in both submissions.  The string added by Emdeon would seem to break the requirement by DentiCal.  DentiCal "has no funds" to refine their interfaces, so there may not be a workable solution. 

DentalXChange replaces (but stores) the claim ID received on the claim with a unique claim ID since very few PMS programs supply unique numbers. You are able to search claims by either ID in ClaimConnect so that you will have the unique claim ID available if checking on a claim with a Payer.

Regardless of which clearinghouse is used, Open Dental does not submit an identical string in the claims as was submitted in the preauthorization.  This behavior is consistent with the X-12 specifications, but does not follow the DentiCal requirements.  It is a feature request to be able to send an identical CLM01 in both a preauth and subsequent claim.

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 Claim Edit window.  Also see the discussion further down regarding the Original Reference Number in 2300 REF (F8).

Quadrants
From time to time, we get complaints about claim rejections due to missing quadrants.  We have reviewed numerous paper and electronic claims in response to the various complaints, but have never found a problem.  The quadrant is clearly listed every time.  On paper claims, there is a column labeled "25. Area of Oral Cavity".  In this column, there should be a number, either 10, 20, 30, or 40 that corresponds to the quadrants UR, UL, LL or LR.  Due to rejections by insurance companies, we began tacking the letter version of the quadrant onto the beginning of the description in addition to sending the number in box 25.
For e-claims, to verify that the number is going out correctly, from the Send Claims window, open the raw text of the sent claim.  It will be easier to troubleshoot if there is only a single claim in the batch.  Look about 2/3 of the way down the claim for the row(s) that start with SV3.   For example, an SRP with code D4341, a fee of $175, performed in an office (11), with a quadrant of UL (20), and a quantity of 1, would look like this:
SV3*AD:D4341*175*11*20**1~
It's easy to see by looking at the SV3 rows that the quadrants are being properly sent. We have never seen a situation where they were not being sent. But if you have an example of such a situation, we would be happy to review it. We continue to be baffled by the periodic claim rejections.

Tooth Ranges
In older versions of Open Dental, there was no mechanism for sending tooth ranges on e-claims.  Only tooth numbers or area of mouth were sent.  Upgrade to 6.8.35 or later for the fix.

Original Reference Number
In the X12 documentation, this is called 2300 REF (F8): Original Reference Number.
In other places, it seems to be called one of the following:
   -Original Document Control Number/Internal Control Number (DCN/ICN).
   -Original Transaction Control Number (TCN).
   -Claim Reference Number.
   -Payer Claim Control Number (in new 5010 documentation)
This field is required by Medicaid when voiding a claim or resubmitting a claim by setting the CLM05-3.  Open Dental does not currently support voiding claims or resubmitting claims, so the TCN fields is currently not sent either.

Attachment Control Number (ACN)
In the X12 documentation, this is placed in the Claim Supplemental Information loop, 2300 PWK06.  To send an ACN in Open Dental, enter the number in the Attachment ID Number field in the Claim Edit window.  There can be only one ACN per claim.

There is a checkbox in the Setup Modules window for: "Requires ACN# in remarks on claims w/ ADDP group name". This is an enforcement policy that was requested by one user. Their carrier expects the ACN# in the remarks of the claim.

Medicaid of Iowa providers may now submit electronic claims relative to an approved Exception to Policy (ETP).  Providers are instructed to enter the Exception to Policy number in the Attachment Control Number (ACN) field 2300 PWK06.  When completing the ACN field the ETP number must be preceded with the letters "ETP". Ex. ETP08-E1234.

Service Authorization Exception Code
In the X12 documentation, this is called 2300 REF: Service Authorization Exception Code.
It is described in the X12 documentation as follows:
Used only in claims where providers are required by state law (e.g., New York State Medicaid) to obtain authorization for specific services but, for the reasons listed in REF02, performed the services without obtaining the service authorization. Check with your state Medicaid to see if this applies in your state.
Open Dental does not currently send or support this code.

Clinics and Providers
Providers should not move between Clinics prior to version 11.1 for the reasons explained here.  In the Send Claims window, we encouraged but did not enforce sending claims for only one clinic at a time.  A batch of claims goes to the clearinghouse as a single heirarchical file, grouped by billing provider.  The billing address for a group of providers is pulled from the first claim in the group under the assumption that the provider/clinic relationship won't change in that group.  This has been resolved in version 11.1 by enforcing batches to all belong to a single clinic.

Billing Address
The logic for which billing address to use for a claim is as follows:
1. If the practice billing address has the box checked for "use on claims", that billing address is used.
2. Else if the claim does not have an attached clinic, the main practice address is used.
3. Else the clinic address is used.
Feature request #2018: Clinic billing address for each separate clinic. For use on claims.
But that request only applies if a billing address is needed for each clinic which is different from the regular clinic address treatment location.

Service Facility Address
There are no fields for sending this information electronically in a 4010.  So service address is always the same as the billing address.  The new 5010 format does have these fields.

5010
The industry-wide transtion from 4010 to 5010 is currently underway.  We already support 5010 format starting with version 11.1.  After 1/1/12, you can try sending version 5010 claims by changing the eformat field in the Clearinghouse edit window. 

Institutional Claims (837I and UB04)

Billing Provider PO Box
There is a new requirement in 5010 that the billing address be a physical address and not a PO Box.  To help support this requirement, we have added a Pay-To address in the Practice Setup window in version 12.0.  The Pay-To address may be a PO Box, and it will be sent in addition to the billing address.  Starting 1/1/12, many carriers (payers) will begin rejecting PO Boxes in the Billing address.  This applies to both 4010 and 5010, but you will need to use 5010 in Open Dental if you wish to send a Pay-To address.  A transition plan should include contacting payers in advance of making changes to verify requirements and update enrollment records.