AGENCY: Department of Health and Human Services. Healthcare Administration. Division of Integrated Healthcare. Office of Eligibility Policy

SERIES: 8059
TITLE: Dentist invoice
DATES: 1985-
ARRANGEMENT: None

DESCRIPTION: These are invoices submitted by dentists for reimbursement for services provided under the medicare and medicaid program. They include name, address, date of birth and sex of the patient, whether the client has health insurance other than medicaid, and, if so, the policy number, and the name and address of the insurance company, the name and license number of the provider, if the treatment was due to accident, Early and Periodic Screening, Diagnosis and Treatment Services, or child abuse, the prior authorization number, a description of the services provided indicating which teeth were worked on, a description of the service provided, the date the service was performed, the procedure code, the charge per service, the name address, and medicaid provider number of the health care provider, the total charges, the signature of the health care financing reviewer, the date the form was reviewed, and the reviewer identification number, and the signature and date of signature of the medicaid provider.

RETENTION

Retain for 1 year(s)

DISPOSITION

Destroy.

RETENTION AND DISPOSITION AUTHORIZATION

These records are in Archives' permanent custody.

APPROVED: 10/1986

FORMAT MANAGEMENT

Paper: Retain in Office for 1 month and then transfer to State Records Center. Retain in State Records Center for 11 months and then destroy.

APPRAISAL

Administrative

This record is microfilmed as it arrives as part of Medical Claims records series and the information on the form is also input into the computer. Therefore, the paper copy only needs to be kept long enough to verify the on-line data.

PRIMARY DESIGNATION

Private

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