Bright Smiles from Birth Coding and Billing Fact Sheet

Posted on: April 13, 2011

Bright Smiles from Birth is an ICAAP educational program that provides guidelines and support to Pediatricians and Family Physicians, Dentists, and families to make oral health a component of well child visits.

Illinois Medicaid:

-Pays $26 per fluoride varnish application on children under 36 months
-Each child may receive up to 3 applications per year (year begins at first application)
-Provider must have been trained in the Bright Smiles from Birth curriculum and provided his or her Medicaid number to ICAAP staff
-Providers must practice in one of the pilot program areas

For Physician Offices:

Form 2360 should be submitted for paper claims and HIPAA transaction 837P should be used for electronic claims. Physicians must bill D1206 on a separate claim or the claim will reject.

For FQHCs:

FQHCs should submit Form 2360 or Form 1443 for paper claims and HIPAA transaction 837P should be used for electronic claims. All services provided during the FQHC visit with the fluoride varnish application (the D1203 code) should be included on a single claim. When an FQHC has a dental clinic, the medical clinic and the dental clinic both use the same provider number, but bill on different claim forms. Services provided in the dental clinic are billed on a dental claim form. The claim identifies the specific dentist who provides the service and is submitted directly to DentaQuest. Medical services are billed on an encounter form and are submitted to the Illinois Department of Healthcare and Family Services (formerly Public Aid). Fluoride varnish applied by a physician would be billed on an encounter form and submitted to Healthcare and Family Services. A separate claim is NOT required for FQHCs. For example, the form could include an E&M visit and a D1206 fluoride application.


Bright Smiles from Birth Coding and Billing Instructions (pdf).

Sample Billing Form for FQHC (pdf).

Sample billing Form for Physicians (pdf).

For more information regarding billing or with specific questions regarding billing, please contact the Bureau of Comprehensive Health Services at 1/877-782-5565.


For more information about Bright Smiles From Birth please contact:

Jennie Pinkwater
Director, Prevention Projects
1400 W. Hubbard
Chicago, IL 60642
Phone: 312/733-1026, ext 213
Fax: 312/733-1791