Symptoms

Use this article when staff need:

• claim examples for onboarding,

• mock training cases,

• rejection examples,

• or premium and prior approval test cases.

Cause

Many clerks understand the code list but still miss the billing logic. Training works better when staff can compare:

• valid routine claims,

• valid premium claims,

• claims needing manual review,

• claims needing prior approval,

• and claims likely to reject or pay zero.

Resolution

A. Successful routine claims

Test case 1 — routine hospital consultation

Scenario
Patient is referred and seen in hospital by the dentist for a true consultation.

Likely code
T650

Expected result
Routine payable claim, assuming correct fields and no duplicate same-day billing.

Test case 2 — valid follow-up assessment

Scenario
Patient returns within 12 months for reassessment of the same diagnosis.

Likely code
T651

Expected result
Potentially payable if the service fits the follow-up rule and is not a duplicate same-day claim.

B. Premium claims

Test case 3 — non-elective evening surgery

Scenario
Emergency dental surgery begins at 7:30 p.m. on a Sunday.

Likely coding approach
Base surgical code + T809

Expected result
Potentially payable with 30% premium if all non-elective and timing conditions are met.

Test case 4 — non-elective overnight surgery

Scenario
Emergency dental surgery begins at 2:10 a.m.

Likely coding approach
Base surgical code + T810

Expected result
Potentially payable with 50% premium if the service qualifies.

Test case 5 — valid virtual consultation

Scenario
Hospital-based dentist performs a virtual consultation, and the chart includes start and stop times.

Likely code
T655, and possibly a related premium code if the timing/setting rules are also met.

Expected result
Potentially payable if all virtual-care conditions are satisfied.

C. Manual review claims

Test case 6 — same-day T650 with odontectomy

Scenario
Patient is assessed and taken to same-day odontectomy with emergency justification.

Likely coding approach
T650 + surgical code, with supporting documentation / manual review workflow

Expected result
May be payable after review if documentation supports the same-day consultation rationale.

Test case 7 — unlisted surgical claim

Scenario
Hospital dental surgery does not fit a listed code cleanly.

Likely code
T800

Expected result
Independent consideration, not routine straight-through billing.

D. Prior approval claims

Test case 8 — prior-approved Part III extraction case

Scenario
Medically necessary hospital dental surgery was approved before service.

Likely coding approach
Applicable Part III code such as a code within T901–T912

Expected result
Potentially payable if the approval, hospitalization need, and code match.

Test case 9 — T650 added to prior-approved Part III claim

Scenario
Clerk bills T650 on the same claim as a prior-approved Part III dental procedure.

Expected result
Expect T650 to pay zero.

E. Common rejection / zero-pay cases

Test case 10 — private office in hospital building

Scenario
Clerk bills T650 for a patient seen in a private dental office located inside the hospital.

Expected result
Likely not payable as a hospital consultation.

Test case 11 — duplicate same-day T651

Scenario
Same dentist bills T651 twice for the same patient on the same day.

Expected result
The excess claim should pay zero.

Test case 12 — virtual visit missing start/stop times

Scenario
T655 or T656 is billed but the chart has no start and stop times.

Expected result
Claim is at risk of non-payment.

Test case 13 — stale-date submission

Scenario
Valid claim is submitted after the three-month billing window.

Expected result
Claim is at risk of rejection or corrective follow-up.

Supervisor training tip

For onboarding, teach clerks to sort every test case into one of five buckets:

• routine payable,

• payable with premium,

• payable after manual review,

• payable only with prior approval,

• likely reject / zero-pay.

That method is more useful than memorizing codes without context.