Condition/Tooth Status - Dental

The Condition/Tooth Status section displays information on conditions relating to the claim and status of the teeth. Users may click the (+) icon to add an additional Tooth Status. The maximum number of statuses is 32.

The Condition/Tooth Status fields are defined below:

Condition Indicator Information

Predetermination IdentifierPredetermination Identifier

Code indicating that the associated claim is a predetermination of benefits request rather than a claim or encounter. Identifier assigned to a predetermination of benefits. Code is received after an initial claim is sent submitting a Predetermination of Benefits.

Service Authorization Exception CodeService Authorization Exception Code

Code identifying a service authorization exception. Used only in claims where providers are required by law to obtain authorization for specific services, but for the reasons listed, performed the service without obtaining the service authorization. Check with your Medicaid to see if this applies in your state. Allowable values for this field include:

1	Immediate/Urgent Care
2	Services Rendered in a Retroactive Period
3	Emergency Care
4	Client has Temporary Medicaid
5	Request from County for Second Opinion to Determine if Recipient Can Work
6	Request for Override Pending
7	Special Handling

Submit for PredeterminationSubmit for Predetermination

Mark check box if the claim is being submitted as a Predetermination of Benefits. Indicates services have been previously predetermined and are now being submitted for payment.

Orthodontic Treatment Months

Tot Ortho Treatment MonTot Ortho Treatment Mon

Estimated number of treatment months for orthodontic treatment.

Months RemainingMonths Remaining

Number of treatment months remaining for orthodontic treatment.

Ortho Treatment IndOrtho Treatment Ind

Code indicating that reported treatment was for orthodontic purposes.

Special Program/Delay Reason

Special Program CodeSpecial Program Code

Code indicating the Special Program under which services rendered to the patient were performed. Values for this field include:

02	Physically Handicapped Children's Program
03	Special Federal Funding
05	Disability
09	Second Opinion or Surgery

Delay Reason CodeDelay Reason Code

Code indicating why a request was delayed. Values for this field include:

1	Proof of Eligibility Unknown or Unavailable
2	Litigation
3	Authorization Delays
4	Delay in Certifying Provider
5	Delay in Supplying Billing Forms
6	Delay in Delivery of Custom-made Appliances
7	Third Party Processing Delay
8	Delay in Eligibility Determination
9	Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules
10	Administration Delay in the Prior Approval Process
11	Other
15	Natural Disaster

Tooth Status

Tooth CodeTooth Code

Tooth number - Up to 32 may be entered. Click the (+) icon to add an additional tooth status.

Tooth Status CodeTooth Status Code

Code(s) used to identify condition(s) relating to the status of the tooth. Click the (+) icon to add an additional tooth status. Options are:

E	To be Extracted
M	Missing

Conditions Tab

CC_Dental_Conditions