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Module 7: Advanced Tools & Integrations

Module 3.14 – Billing Directly to Insurance

Billing directly to insurance can be done by creating a CMS 1500 form or integrating IntakeQ with an insurance billing software, such as Trizetto or Office Ally. You can integrate these softwares by navigating to Home > More > Settings and clicking on the “integrations” tab. Be aware that not all states authorize direct reimbursement for the RDH.

If you are filling out the CMS 1500 form, here’s what you need to know about how to properly fill it out:

  • A blank space for carrier (payer) information is located in the upper right side of the form. This information is typically found on the patient’s insurance card where it says “Submit claims to” followed by an address.
  • Boxes 1-11: This section is for information on the patient and the insured. If the patient is a child, you will want to include information on the parent or guardian who holds the insurance. Sometimes the patient will be the insured (policy-holder). In this case, you will not need to input the same information on the “insured” section. You can write “same” in box 4 and “same” in box 7. If the patient is dually-insured, you will want to fill out the “other insured” section. Other insured means that there is second-party coverage. If the child is dually-insured with Medicaid, Medicaid should not be billed until other payers have had opportunity to pay. In this case, you would not the Medicaid plan in the “other insured” section. After you have billed the primary payer, you may bill to Medicaid. In this case, you will list the private insurance plan in the “other insured” section. If the primary payer has paid, you would include the amount in the “amount paid” section. You will always enter the primary payer’s contribution in this section (box 29).
  • Boxes 12-13: In the patient or authorized person’s signatures section, you’ll want to make sure that your patient has signed a form authorizing you to submit claims to their insurance companies on their behalf. Once your patient has signed an agreement, you can simply state “signature on file” or “SOF” in the signature lines of both of these boxes and the date the signature was received in the date line. Note: If you sign box #13, the signature authorizes the payment to be sent to you directly. If you do not sign this box, the payment will go directly to the patient. Not every state allows for direct insurance billing/reimbursement for the dental hygienist.
  • Boxes 14-20: These are typically left blank, but you may want to include referring physician information in box 17. This is required information by Medicare. If you do not know the referring physician’s NPI number, for 17-B you can search for it on a website like https://www.npinumberlookup.org. It is unlikely that you will need to complete 17-A.
  • Box 21: Box 21 allows you to list ICD-10 codes. Only list the codes relevant to the services you are providing.
  • Box 22: This is only relevant for resubmitted or corrected claims.
  • Box 23: If you have a prior authorization number (we recommended that you receive prior authorization), you will enter it on this line.
  • Box 24: In this section, each block will require its own line.
    • In box 24-A, you will enter the date of service for each service.
    • In box 24-B, you will enter the two-digit place of service code. More information on place of service codes can be found in module 3.5.
    • Box 24-C is an “emergency” indicator, which is not applicable to orofacial myofunctional therapy services.
    • In box 24-D, you will list the CPT service code. More information on CPT codes can be found in module 3.3.
    • In box 24-E you will apply the corresponding letter for the appropriate codes match with to match the services rendered.
    • In box 24-H, EPSTDT stands for “Early & Periodic Screening, Diagnosis, and Treatment.” It is unlikely for the orofacial myologist will be doing these screens. If you are not providing EPSTDT-related services, you can either write “N” or leave it blank.
    • Box 24-I, will typically be left blank.
    • In box 24-J, you will enter your NPI number next to “NPI.” More information on NPI number can be found in module 3.1.
  • Box 25 is for your EIN number without any hyphens or spaces. More information on the EIN can be found in module 3.1.
  • Box 26 is optional but allows you to enter your patient’s account number. You can find your patient account number in IntakeQ by navigating to Home > Lists > Clients. From there, find your patient’s chart. The ID number is to the left-hand side of your patient’s name.
  • Box 27 is asking if you agree to accept the total reimbursement allowed by the payer (includes insurance payer’s payment, copayments, and deductible contributions). Most contracts with insurance payers will require that you accept assignment as payment in full.
  • Box 28 is the total charge for all service dates listed on the form (the sum of monies in column F).
  • Box 29 is for the amount paid by the patient and/or other payers toward the service. If you have not already collect copayment, leave this blank.
  • Box 31 is reserved for NUCC use. You do not need to complete this section.
  • Box 32 is for you to sign and date.
  • Box 33 is for your name or your company’s name, address, and pone number. If you are receiving payment directly, it will be sent to this address. Box 33-A is for your NPI number.

When a claim has been paid by the payer, you will receive a copy of the EOB (Explanation of Benefits), and the patient will too. You will want to make sure you keep all CMS 1500 and EOBs on file in the patient chart/client profile:

Helpful links: