<html> <head> <title>Rule 20:06:27:05 Requirements for use of J512 Form.</title> <META NAME="Keywords" Content="Administrative Rules 20:06:27:05"> <META NAME="Description" Content="Administrative Rules 20:06:27:05 Requirements for use of J512 Form."> <meta name=Generator content="Microsoft Office HTML Filter 2.0"> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Originator content="Microsoft Word 10"> <style> <!-- --> </style> </head> <body lang=EN-US> <div> <p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>20:06:27:05.&nbsp;&nbsp;Requirements for use of J512 Form.</b> The J512 Form shall be used as follows:</p> <p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (1)&nbsp;&nbsp;Dentists shall use the Dental Claim Form, J512, adopted by the American Dental Association as of 1994, according to instructions contained in the American Dental Association's Current Dental Terminology CDT-2, 1995-2000, for filing claims with issuers for professional dental services. When requested by the patient, dentists that bill patients directly shall provide the patient with a completed J512 Form in addition to any other form used to bill the patient;</p> <p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (2)&nbsp;&nbsp;Issuers may not require a dentist to use any code other than the CDT-2 codes for the initial filing of claims for dental care services, unless the use of supplemental codes is defined and permitted in a written contract between the issuer and dentist;</p> <p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (3)&nbsp;&nbsp;Dentists performing procedures within their scope of practice which do not have assigned CDT-2 codes may use the HCFA 1500 Form with the applicable CPT-4 codes. Issuers must accept the J512 Form or, as applicable, the HCFA 1500 Form.</p> <p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Source:</b> 22 SDR 97, effective December 18, 1995.</p> <p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>General Authority:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-12-14">58-12-14.</A></p> <p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Law Implemented:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-12-12">58-12-12.</A></p> <p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>References:</b> <b>Form J512</b>, adopted in 1994, American Dental Association. Copies may be obtained from the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Cost: $25.20, plus $3.95 for shipping and handling.</p> <p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Current Dental Terminology CDT-2</b>, Second Edition, 1995-2000, American Dental Association. Copies may be obtained from the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Cost: $29.95.</p> <p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Physicians' Current Procedural Terminology CPT</b><b>'95</b>, Fourth Edition, 1994, Health Care Financing Administration, U.S. Department of Health and Human Services. Copies may be obtained from the American Medical Association, P.O. Box 7046, Dover, DE 19903-7046. Cost: $41.95, plus shipping and handling.</p> </div> </body> </html>