NEW DENTAL CLAIM FORM REQUIREMENTS EFFECTIVE 01/01/05
Currently, Medicaid accepts the 1990, 1994 and 2002 American Dental Association (ADA) Claim Forms for prior authorization and reimbursement of dental hardcopy claims. Effective January 1, 2005, the 2002 American Dental Association Claim Form and the 2002, 2004 American Dental Association Claim Form will become the only hardcopy dental claim forms accepted for Medicaid prior authorization and reimbursement of services provided under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Dental, Expanded Dental Services for Pregnant Women (EDSPW) and Adult Denture Programs regardless of the date of service.
All dental claims received by Molina Medicaid Solutions or the LSU Dental School, Medicaid Dental Prior Authorization Unit prior to January 1, 2005 on the older versions of the American Dental Association (ADA) Claim Form will be processed. In-house and pending claims received on the older versions of the ADA claim form will be processed. However, on or after January 1, 2005 any dental claims received by Molina or the LSU Dental School, Medicaid Dental Prior Authorization Unit on the older versions of the ADA Claim Form will be returned to the provider.
Hardcopy billing providers who are currently using older versions of the ADA Claim Form should request the 2002 ADA Claim Form or the 2002, 2004 ADA Claim Form from the ADA as soon as possible in order to be compliant with this requirement by January 1, 2005.
Providers who are currently using older versions of dental software to print hardcopy dental claims should contact their software vendor as soon as possible for updated (2002 or 2002, 2004) dental software in order to be compliant with this requirement by January 1, 2005.
Should you have any questions regarding this information, you may contact Molina Provider Relations by calling (800) 473-2783 or (225) 924-5040 or the Medicaid Dental Prior Authorization Unit by calling 504-619-8589.