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Submit Services for Accidental Dental Injuries as a Medical Claim

Horizon Dental reminds dentists that services for accidental dental injuries are usually covered under the patient’s medical, not dental, plan, and will be processed according to the medical plan benefits.

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Even if your patient has both medical and dental coverage with Horizon Blue Cross Blue Shield of New Jersey, you must submit a medical claim electronically or by mail using a claim form for the patient’s medical plan. Please do not use the dental claim form for a medical claim.

When completing the medical claim form, include either CPT® or CDT® codes to describe the procedure(s) performed. An ICD-10 diagnosis code must also be included and indicate this claim is related to an accident. This will help route the claim to the appropriate department. In addition, please include the following with the claim:

  • Diagnostic X-rays pre- and post- accident, when applicable
  • All chart notes
  • A complete treatment plan

In addition, please check for eligibility, since claims for the treatment of accidental dental injuries are limited, based on plan, to a maximum of one year after the accident. All non-emergent treatment should be pre-authorized so members have a clear understanding of their out-of-pocket cost prior to treatment.

Examples of CPT Codes

  • 99201 – 99205: Office Visit for a New Patient. The level used depends on the level of complexity and time you spend with the patient. For example, a 99201 would be similar to a limited oral evaluation of a D0140. Code 99203 would be similar to code D0120.
  • 99211 – 99215: Office Visit for an Established Patient. The same analog of levels apply as above.
  • 70355: Panorex Radiograph

Examples of ICD-10 Codes for Accidental Dental Injuries

  • S03 Dislocation and sprain of joints and ligaments of head
    • S03.2 Dislocation of tooth
      • S03.2XXA Dislocation of tooth, initial encounter
      • S03.2XXD Dislocation of tooth, subsequent encounter
      • S03.2XXS Dislocation of tooth, sequela
  • S02 Fracture of skull and facial bones
    • S02.5 Fracture of tooth (traumatic)
      • S02.5XXA Fracture of tooth (traumatic), initial encounter for closed fracture
      • S02.5XXB Fracture of tooth (traumatic), initial encounter for open fracture
      • S02.5XXS Fracture of tooth (traumatic), sequela
      • S02.5XXK Fracture of tooth (traumatic), subsequent encounter for fracture with nonunion
      • S02.5XXD Fracture of tooth (traumatic), subsequent encounter for fracture with routine healing
      • S02.5XXG Fracture of tooth (traumatic), subsequent encounter for fracture with delayed healing

If you have questions about electronic submission of a claim form, please call the e-Service Desk at 1-888-334-9242.