Canada Claim Form
Below is an explanation of how each field on the printed Canadian Claim Form is populated.
Note: The requirements for e-claims are different than the requirements for paper claims. Printing a claim does not represent what is sent in an e-claim. Likewise information sent in an e-claim does not necessarily print on a paper claim.
| Area / Field Name | Claim Form Item Used | Where Entered |
|---|---|---|
| Part 1 - Dentist | ||
| Patient | PatientLastFirst | Edit Patient Information window, last and first name |
| PatientAddress | Edit Patient Information window, Address | |
| PatientAddress2 | Edit Patient Information window, Address2 | |
| PatientCity | Edit Patient Information window, City | |
| PatientST | Edit Patient Information window, Province | |
| PatientZip | Edit Patient Information window, Postal Code | |
| Unique No. | TreatingDentistNPI | Provider Edit window, CDA number |
| Spec. | Not entered | |
| Patients Office Account No | PatientPatNum | Edit Patient Information window, Patient Number |
| Dentist | TreatingDentist | Edit Provider window, first name, last name, middle initial, suffix. Displays treating provider on claim. |
| PayToDentistAddress | Edit Practice Info window, Pay To Address. If blank, uses physical treating address. | |
| PayToDentistAddress2 | Edit Practice Info window, Pay To Address 2. If blank, uses physical treating address. | |
| PayToDentistCity | Edit Practice Info window, Pay To City. If blank, uses physical treating address. | |
| PayToDentistST | Edit Practice Info window, Pay To St (province). If blank, uses physical treating address. | |
| PayToDentistZip | Edit Practice Info window, Pay To Zip. If blank, uses physical treating address. | |
| TreatingDentistPhoneRaw | Edit Practice Info window, Phone | |
| I hereby assign... | Patient Assignment | Edit Insurance Plan window. When Assignment of Benefits is checked, Signature on File shows. |
| For Dentist Use Only | Remarks | Line 1: If predetermination, shows Predetermination Only. If Assignment of Benefits is checked, shows Please pay patient. Line 2: Shows notes entered in Edit Claim window, General Tab, Claim Note. |
| I understand that the fee... | TotalFee | Fee billed to insurance for all items on claim. |
| Signature of Patient | PatientRelease | Edit Insurance Plan window. When Release of Information is checked, Signature on File shows. |
| Date of Service | P1Date, etc | Procedure Info window, Date |
| Procedure Code | P1Code, etc | Procedure sent to insurance |
| Intl Tooth Code | P1ToothNumOrArea, etc | Treatment area of procedure code, if any |
| Tooth Surfaces | P1Surface, etc | Tooth surface of procedure code, if any |
| Dentists Fee | P1FeeMinusLab, etc | Fee billed to insurance for procedure, minus the lab fee, if any. |
| Laboratory Charge | P1Lab, etc | Lab fee associated with procedure |
| Total Charges | P1Fee, etc | Sum of Dentist's fee and lab charges for the procedure code |
| Total Fee Submitted | TotalFee | Sum of Total Charges for all procedures |
| Part 2 - Employee/Plan Member/Subscriber | ||
| Group Policy/Plan No | GroupNum | Edit Insurance Plan window, Plan Number |
| Division/Section No | DivisionNum | Edit Insurance Plan window, Div. No. |
| Your Name | SubscrLastFirst | Edit Patient Information window, last and first name of subscriber |
| Employer | EmployerName | Edit Insurance Plan window, Employer |
| Your Cert No or SIN or ID No | SubscrIDStrict | Edit Insurance Plan window, Subscriber ID |
| Name of Insurance Agency or Plan | PriInsCarrierName | Edit Insurance Plan window, Carrier |
| Your Date of Birth | SubscrDOB | Edit Patient Information window, Birthdate of subscriber |
| Part 3 - Patient Information | ||
| Patient Relationship to Employee/Plan Member/Subscriber | Relationship | Edit Insurance Plan window, Relationship to Subscriber |
| Date of Birth | PatientDOB | Edit Patient Information window, Birthdate |
| If child indicate... Student | Is Student | Edit Patient Information window, Other tab, Eligibility Excep Code 1 or 3 |
| If child indicate... Handicapped | Not entered | |
| If student, indicate school | College Name | Edit Patient Information window, Other tab, Name of school |
| Patient ID No | PatIDFromPatPlan | If carrier is Pacific Blue Cross, then: Edit Insurance Plan window, Subscriber ID If any other carrier, then: Edit Insurance Plan window, Dependent Code |
| Are any dental benefit or services... No | OtherInsNotExists | If no secondary coverage |
| Are any dental benefit or services... Yes | OtherInsExists | If secondary coverage exists |
| Policy No | OtherInsGroupNum | Edit Insurance Plan window, Plan Number (of secondary insurance, if any) |
| Spouse Date of Birth | OtherInsSubscrDOB | Edit Patient Information window, Birthdate (of secondary coverage subscriber) |
| Name of other insuring agency or plan | OtherInsCarrierName | Edit Insurance Plan, Carrier (of secondary coverage) |
| Signature of Employee/Plan Member/Subscriber | Not entered | |
| Is any treatment required as the result of the accident?No | IsNotAccident | Edit Claim window, Canadian tab. No accident date entered. |
| Is any treatment required as the result of the accident?Yes | IsAccident | Edit Claim window, Canadian tab. Accident date entered. |
| If Denture, Crown or Bridge... No | IsReplacementProsth | Edit Claim window, Canadian tab. Maxillary Prosthesis and Mandibular Prosthesis - 1 No and the other not entered or both No |
| If Denture, Crown or Bridge... Yes | IsInitialProsth | Edit Claim window, Canadian tab. Maxillary Prosthesis and Mandibular Prosthesis - 1 Yes and the other not entered or both Yes |
| Is any treatment required for ortho... No | IsNotOrtho | Edit Claim window, Canadian tab, Treatment Required for Ortho, not checked |
| Is any treatment required for ortho... Yes | IsOrtho | Edit Claim window, Canadian tab, Treatment Required for Ortho, checked |
| Date | PatientReleaseDate | Edit Claim window, Date Sent. |
| Part 4 - Policy Holder / Employer | Not entered. If needed, must be filled by hand. |