Treatment date

• Correctly and accurately report every date that a dental service was actually performed or completed. Multi-staged procedures such as crowns, bridges, dentures and root canal treatment should be submitted upon insertion or completion.

Treatment Rendered

• Correctly and accurately report each dental service or procedure that was rendered.

Coordination of Benefits

• Correctly and accurately report all other benefit coverage and insurance payments for the dental services.

Disclosure of waiver

• Legibly and conspicuously disclose on the face of the claim any intention to waive a patient's copayment responsibility.

Disclosure of discounts

• Correctly and accurately disclose any discounts extended to the patient for these services.

• Correctly and accurately disclose any reduced fees that resulted from the use of coupons.

Disclosure of "free" services

• Correctly and accurately reflect the fee of the services actually being charged and collected from the patient.

Services not performed

• Report only services that are actually performed.

Identification of appropriate dentist

• Correctly identify both the billing dentist and the treating dentist by name and license number.

Barter

• Only reflect the actual amounts being collected in actual currency. Delta Dental does not make payment based on bartering services.

Failure to correctly perform the above checks will result in a violation of the Delta Dental of New Jersey Participation Agreement and may also result in the violation of:

• The New Jersey Insurance Fraud Prevention Act

• Other State and Federal Laws