| [4] Other Dental or Medical Coverage | One of the following options display the payer details when the patient has coverage under any dental or medical plan:
- Blank
Note: If you select Blank, then nothing prints in Boxes 5-11.
- Dental/Medical
- Checks Dental box, if other coverage is the non-primary payer and the Payer Defaults 2 tab is selected.
- Checks Medical box when payer is primary.
Note: Boxes 5-11 print with correct data for both types of coverage.
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| [31a] Other Fee(s) – Line 1 – When zero dollar amount, display | One of the following options display the fee of the other charges applicable to dentist services when the amount is zero-dollar:
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| [31a] Other Fee(s) – Line 1 | One of the following options display the fee of the other charges applicable to dentist services:
- Adjustments only
Includes all previous adjustments (payer or contractual) from all COB levels.
- All payer payments
Includes all previous payer payments from all COB levels.
- All payer payments + Adjustments
Includes all previous payer payments plus all previous adjustments (payer or contractual) from all COB levels.
- Blank
- Patient paid amount
Includes all previous patient payments.
- Patient paid amount + Adjustments
Includes all previous patient payments plus all previous adjustments (payer or contractual) from all COB levels.
- Patient paid amount + All payer payments
Includes all previous patient payments plus all previous payer payments from all COB levels.
- Patient paid amount + All payer payments + Adjustments
Includes all previous patient payments, payer payments, and all previous adjustments (payer or contractual) from all COB levels.
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| [32] Total Fee - When zero dollar amount, display | One of the following options display the sum of all fees from Box 31 and from Box 31a when the amount is zero-dollar:
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| [32] Total Fee | One of the following options display the sum of all fees from Box 31 and from Box 31a:
- Blank
- Sum of all charges
- Sum of all charges minus Box 31a – Line 1
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