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DENTAL CLAIMS BILLING INSTRUCTIONS
Delay Reason Code:
Select the appropriate code from the drop-down list to identify the reason for delay in submitting the claim.
Code
1
2
3
4
5
Description
Proof of eligibility unknown or unavailable
Litigation
Authorization delays
Delay in certifying provider
Delay in supplying billing forms
Remarks:
Format:
Optional
N
DENTAL HEADER THREE
DENTAL HEADER THREE INFORMATION
DESCRIPTION
DIAGNOSIS CODES 1-4
ACCIDENT RELATED CAUSES 1-2
DATE
STATE
COUNTRY
FIELD
LENGTH
REQUIRED (R)
OPTIONAL (O)
SITUATIONAL (S)
ALPHA/
NUMERIC
5
2
8
2
3
O
S
S
S
S
X
A
N
A
A
HPE PROVIDER ELECTRONIC SOLUTIONS USER’S MANUAL
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