Send Completed Forms to:
ASO INC.
PO Box 9005
Lynbrook, NY 11563
877-844-7667
asombf.com
PLEASE SUBMIT PRE-OPERATIVE X-RAYS FOR INLAYS, CROWNS, BRIDGES,
DENTURES, PERIO SURGERY, ROOT CANAL THERAPY
AND NON-ROUTINE EXTRACTIONS.
X-RAYS OF FULL ARCH REQUIRED FOR ALL BRIDGE WORK.
POST TREATMENT X-RAYS REQUIRED FOR ALL ROOT CANAL THERAPY CLAIMS.
9. Plan/Group Number
16. Plan/Group Number
17. Employer Name/Group Name
10. Patient’s Relationship to Person named in #5
11. Other Insurance Company/Dental Benet Plan Name, Address, City, State, Zip Code
Self Spouse Dependent Other
Dental?
Medical?
(If both complete 5-11 for dental only)
HEADER INFORMATION
INSURANCE COMPANY/DENTAL BENEFIT PLAN INFORMATION
POLICYHOLDER/MEMBER INFORMATION
PATIENT INFORMATION
V53
OTHER COVERAGE
1. Type of Transaction (Mark all applicable boxes)
(Mark applicable box and complete items 5-11. If none, leave blank.)
Request for Predetermination/Preauthorization
2. Predetermination/Preauthorization Number
3. Company/Plan Name, Address, City, State, Zip Code
4.
5. Name of Policyholder/Member in #4 (Last, First, Middle Initial, Sux)
6. Date of Birth (MM/DD/YYYY) 7. Gender
8. Policyholder/Member ID (SSN or ID#)
12. Policyholder/Member Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code
(For Insurance Company Named in #3)
Statement of Actual Services
M F
18. Relationship to Policyholder/Member in #12 Above 19. Reserved For Future Use
20. Name (Last, First, Middle Initial, Sux) Address, City, State, Zip Code
Self Spouse
Dependent Child
Other
13. Date of Birth (MM/DD/YYYY) 14. Gender
15. Policyholder/Member ID (SSN or ID#)
M F
21. Date of Birth (MM/DD/YYYY) 22. Gender
23. Patient ID/Account # (Assigned by Dentist)
M F
RECORD OF SERVICES PROVIDED - TO BE COMPLETED BY DENTIST
24.
Procedure Date
(MM/DD/YYYY)
25.
Area of
Oral Cavity
26.
Tooth
System
27.
Tooth Number(s)
or Letter(s)
29.
Procedure
Code
28.
Tooth
Surface
29a.
Diagnostic
Pointer
29b.
Quantity
30.
Description
Fee
1
2
3
4
5
6
7
8
9
10.
33. Missing Teeth Information (Place an “X” on
1 2 3 4 5 6 7 8 9 10
11 12 13 14 15 16
31a. Other
each missing tooth)
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17
Fee(s)
35.
Remarks
32.
Total Fee
AUTHORIZATIONS
ANCILLARY CLAIM TREATMENT INFORMATION
36. I have been informed of the treatment plans and associated fees. I agree to be responsible for all
charges for dental services and materials not paid by my dental benet plan, unless prohibited by
law, or the treating dentist or dental practice has a contractual agreement with my plan prohibiting
all or a portion of such charges. To the extent permitted by law, I consent to your use and disclosure
of my protected health information to carry out payment activities in connection with this claim. I
understand that benefits will automatically be assigned to my dentist if he or she is a Participating
Provider.
X
_________________________________________________________________________________
Signed (Patient or Member/Guardian) Date
___________________________________________________________________________________
37. I hereby authorize and direct payment of the dental benets otherwise payable to me, directly
to the below named dentist or dental enti
ty, if allowed under my group guidelines. I understand that
benefits will automatically be assigned to my dentis
t if he or she is a Participating Provider.
X
_________________________________________________________________________________
Signed (Member/Guardian) Date
38. Place of Treatment
39. Enclosures?
34. Diagnosis Code List Qualier
34a. Diagnosis Codes
(Primary diagnosis in “A”)
(ICD-9 = BB; ICD-10 = AB)
40. Is Treatment for Ortho
dontics? 41. Date Appliance Placed (MM/DD/YYYY)
No (Skip 41-42 ) Yes (Complete
(Complete 44)
(e.g 11 = Oce; 22 = O/P Hospital)
(Use “Place of Service Codes for Professional Claims”)
41-42)
42. Months of Treatment 43
53.
.
Replacement of Prosthesis 44. Date of Prior Placement (MM/DD/YYYY)
45. Treatment Resulting from (check applicable box)
Occupational Illness/Injury Auto Accident
Other Accident
46. Date of Accident (MM/DD/YYYY) 47. Auto
Accident State
48.
BILLING DENTIST OR DENTAL ENTITY
(Leave blank if dentist or dental entity is not submitting
claim on behalf of the patient or insured/member)
Name, Address, City, State, Zip Code
___________________________________________________________________________________
49. NPI# 50. License Number 51. SSN or TIN
___________________________________________________________________________________
52. Phone Number 52A. Additional Provider ID
TREATING DENTIST AND TREATMENT LOCATION INFORMATION
I hereby certify that the procedure(s) as indicated by date are in progress (for procedures that require multiple
visits) or have been completed and that the fees submitted are the actual fees I have charged and intend to collect
for those procedures.
X
_____________________________________________________________________________________________
Signed (Treating Dentist) Date
_______________________________________________________________________________________________
54. NPI 55. License Number
56a. Specialty Provider Code
_______________________________________________________________________________________________
56. Address, City, State, Zip Code
_______________________________________________________________________________________________
57. Phone Number 58. Additional Provider ID
31.
Rev. 01/23
A
C
B D
No Yes
No Yes
MANAGEMENT BENEFITS FUND
DENTAL CLAIM FORM
Payor ID# CX076
ASO
PO BOX 9005
LYNBROOK, NY 11563
Any person who knowingly and with intent to defra
ud any insurance company or other person fil
es an applicaon for insurance or statement of claim containing any
materially false informaon, or conceals for the purpose of misleading, informaon concerning any fact material ther
eto, commits a fraudulent insurance act, which is a
crime, and shall be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violaon.
GENERAL INSTRUCTIONS
COORDINATION OF BENEFITS (COB)
When a claim is being submied to the secondary payer, complete the enre form and aach the primary payer’s Explanaon of Benefits (EOB) showing the amount paid
by the primary payer. You may also note the primary carrier paid amount in the “Remarks” field (Item 35). There are addional detailed compleon instrucons in the CDT
manual.
DIAGNOSIS CODING
The form supports reporng up to four diagnosis codes per dental procedure. This informaon is required when the diagnosis may affect claim adjudicaon when specific
dental procedures may minimize the risks associated with the connecon between the paent’s oral and systemic health condions. Diagnosis codes are linked to
procedures using the following fields:
Item 29a – Diagnosis Code Pointer (“A” through “D” as applicable from Item 34a)
Item 34 – Diagnosis Code List Qualifier (B for ICD-9-CM; AB for ICD-10-CM)
Item 34a – Diagnosis Code(s) / A, B, C, D (up to four with the primary adjacent to the leer “A”)
PLACE OF TREATMENT
Enter the 2-digit Place of Service Code for Professional Claims, A HIPAA standard maintained by the Centers for Medicare and Medicaid Services. Frequently used codes are:
11 = Office 12 = Home 21 = Inpaent Hospital 22 = Outpaent Hospital 31 = Skilled Nursing Facility 32 = Nursing Facility
The full list is available online at “www.cms.gov/PhysicianFeeSched/Downloads/Website_POS_database.pdf”
PROVIDER SPECIALTY
This code is entered in Item 56a and indicated the type of dental professional who delivered the treatment. The general code listed as “Denst” may be used instead of any
of the other codes.
Complete all items unless noted otherwise on the form or in the CDT manual’s instrucons.
Enter the full name of an individual or a full business name, address and zip code when a name and address field is required.
All dates must include the four-digit year.
If the number of procedures reported exceeds the number of lines available on one claim form, list the remaining procedures on a
separate, fully completed claim form.
A.
B.
C.
D.
Denst
A denst is a person qualified by a doctorate in dental surgery (D.D.S.) or dental medicine (D.M.D.)
licensed by the state to pracce denstry, and praccing within the scope of that license.
122300000X
Category / Descripon Code Code
1223S0112XOral & Maxillofacial Surgery
Provider taxonomy codes listed above are a subset of the full code set that is posted at “www.wpc-edi.com/codes/taxonomy”
Oral & Maxillofacial Radiology 1223D0008X
Oral & Maxillofacial Pathology 1223P0106X
Prosthodoncs 1223P0700X
Periodoncs 1223P0300X
Pediatric Denstry 1223P0221X
Orthodoncs 1223X0400X
1223E0200XEndodoncs
Dental Public Health 1223D0001X
Various
Dental Specialty (see following list)
General Pracce
1223G0001X
39. Enclosures?
Provider Hotline: 1-800-537-1238
E-mail inquiries
For additional information visit asombf.com
Dedicated Customer Service Line for Management Benefits Fund Members: 1-877-844-7667