DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11013 (02/09)
STATE OF WISCONSIN DHS 105.03(1), Wis. Admin. Code
WISCONSIN MEDICAID
URGENT CARE DENTAL IN-STATE EMERGENCY PROVIDER DATA SHEET
Instructions: Type or print clearly. Before completing this form, read the Urgent Care Dental In-State Emergency Provider Data Sheet Completion Instructions, F-11013A. This is required in order to submit claims for urgent dental services. Attach this data sheet to a claim form currently accepted by Wisconsin Medicaid. Submit the completed form with any applicable attachments to ForwardHealth, In-State Emergency Claims, 6406 Bridge Road, Madison, WI 53784-0011. Dental providers may call Provider Services at (800) 947-9627 with any questions. SECTION I -- PRACTICE LOCATION INFORMATION 1. Name -- Provider 2. National Provider Identifier
3. Address Line 1
4. Address Line 2
5. City
6. State
7. ZIP+4 Code
8. County -- County of Provider's Practice
9. License Number
10. Gender Male Female
11. Name -- Contact Person
12. Telephone Number -- Contact Person
SECTION II -- PROVIDER FINANCIAL INFORMATION Taxpayer Information 13. Taxpayer Identification Number (TIN) 14. Name -- Taxpayer
15. TIN Type EIN SSN
16. TIN Effective Date
17. TIN End Date
Checks and Remittance Advice Information 18. Address Line 1 19. Address Line 2
20. City
21. State
22. ZIP+4 Code
23. Name -- Financial Contact Person
24. Telephone Number -- Contact Person
IRS Form 1099 Mailing Address 25. Address Line 1
26. Address Line 2
27. City
28. State
29. ZIP+4 Code
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URGENT CARE DENTAL IN-STATE EMERGENCY PROVIDER DATA SHEET F-11013 (02/09)
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SECTION III -- MAILING INFORMATION 30. Name -- Mail To 31. Name -- Attention Line
32. Address Line 1
33. Address Line 2
34. City
35. State
36. ZIP+4 Code
SECTION IV MEMBER INFORMATION 37. Name -- Member
38. Member Identification Number
SECTION V -- AUTHORIZED SIGNATURE INFORMATION I affirm that services provided are medically indicated and necessary to the patient's health. The services are within the scope of my (our) licensure. I understand that any false claims, settlements, documents, or concealment of material fact may be prosecuted under applicable federal and state law. I further affirm that to the best of my knowledge the information presented here is accurate and complete. 39. SIGNATURE -- Provider or Authorized Agent (Required) 40. Date Signed (Required)
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URGENT CARE DENTAL IN-STATE EMERGENCY PROVIDER DATA SHEET F-11013 (02/09)
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The following services are covered in emergency situations. EMERGENCY PROCEDURE CODES FOR DENTAL CARE CODE D0140 D0220, D0230 D0250 D0260 D0270 D0330 D2140-D2394 D2930 D2931 D2932 D2940 D3220 D3221 D5510 D5520 D5610 D7111, D7140 D7210, D7220, D7230, D7240 D7250 D7260 D7270 D7510 D7520 D7610-D7780 D7820 D7830 D7910-D7912 D9110 D9220 D9241 D9248 D9420 DESCRIPTION Limited oral evaluation -- problem focused Intraoral; periapical -- first films / each additional film Extraoral; first film Extraoral; each additional film Bitewing(s); single film Panoramic film Restorative services Prefabricated stainless steel crown; primary tooth permanent tooth Prefabricated resin crown Sedative filling Therapeutic pulpotomy (excluding final restoration); removal of pulp coronal to the dentinocemental junction and application of medicament Pulpal debridement, primary and permanent teeth Repair broken complete denture base Replace missing or broken teeth -- complete denture (each tooth) Repair resin denture base Extractions Surgical extractions Surgical removal of residual tooth roots (cutting procedure) Oroantral fistula closure Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth Incision and drainage of abscess; intraoral soft tissue extraoral soft tissue Treatment of fractures Closed reduction of dislocation Manipulation under anesthesia Sutures Palliative (emergency) treatment of dental pain -- minor procedures Deep sedation/general anesthesia; first 30 minutes Intravenous conscious sedation/analgesia; first 30 minutes Non-intravenous conscious sedation Hospital call