Free Wisconsin Medicaid Urgent Care Dental In-State Emergency Provider Data Sheet, F-11013 - Wisconsin

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