The ADA Dental Claim Form is a crucial document for the submission of dental claims to insurance companies. It captures detailed information about the policyholder, patient, dental procedures performed, and the financial aspects of the treatment. Completing this form accurately is essential for the timely processing and reimbursement of dental claims. To ensure your claim is processed efficiently, click the button below to learn more about how to fill out the ADA Dental Claim Form correctly.
The American Dental Association (ADA) Dental Claim Form plays a crucial role in the dental care industry, serving as a standardized mechanism for practitioners to submit claims for dental services provided to patients with dental insurance. Its primary purpose is to streamline the reimbursement process from dental benefit plans, ensuring that both patients and providers can manage financial aspects of dental care efficiently. This comprehensive form covers multiple aspects, including detailed information about the policyholder, patient, insurance company, and the specific dental services rendered. It allows for the categorization of transactions, whether they are for actual services performed or requests for predetermination/preauthorization of services. Moreover, it includes sections for documenting other coverage, thereby assisting in the coordination of benefits when a patient is covered by more than one dental plan. It captures patient demographics, details about the dental procedure(s) performed including dates, tooth number(s), and procedural codes, along with any remarks relevant to the claim. The ADA Dental Claim Form also incorporates sections for authorizations and signatures, which are essential for processing the claim and ensuring that the treatment provided is acknowledged by both the patient and the insurance company. This form not only facilitates efficient claims processing but also supports dental practices in managing their billing and insurance reimbursements effectively. Comprehensive instructions for completing this form ensure that all necessary information is accurately captured, paving the way for a smoother transaction between dental providers, patients, and insurance entities.
fold
Dental Claim Form
HEADER INFORMATION
1. Type of Transaction (Mark all applicable boxes)
Statement of Actual Services
Request for Predetermination/Preauthorization
EPSDT/ Title XIX
2. Predetermination/Preauthorization Number
POLICYHOLDER/SUBSCRIBER INFORMATION (For Insurance Company Named in #3)
12. Policyholder/Subscriber Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code
INSURANCE COMPANY/DENTAL BENEFIT PLAN INFORMATION
3. Company/Plan Name, Address, City, State, Zip Code
13. Date of Birth (MM/DD/CCYY)
14. Gender
15. Policyholder/Subscriber ID (SSN or ID#)
M
F
OTHER COVERAGE
16. Plan/Group Number
17. Employer Name
4. Other Dental or Medical Coverage?
No (Skip 5-11)
Yes (Complete 5-11)
5. Name of Policyholder/Subscriber in #4 (Last, First, Middle Initial, Suffix)
PATIENT INFORMATION
18. Relationship to Policyholder/Subscriber in #12 Above
19. Student Status
Self
Spouse
FTS
PTS
6. Date of Birth (MM/DD/CCYY)
7. Gender
8. Policyholder/Subscriber ID (SSN or ID#)
Dependent Child
Other
20. Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code
9. Plan/Group Number
10. Patient’ s Relationship to Person Named in #5
Dependent
11. Other Insurance Company/Dental Benefit Plan Name, Address, City, State, Zip Code
21. Date of Birth (MM/DD/CCYY)
22. Gender
23. Patient ID/Account # (Assigned by Dentist)
RECORD OF SERVICES PROVIDED
24. Procedure Date
25. Area
26.
27. Tooth Number(s)
28. Tooth
29. Procedure
of Oral
Tooth
30. Description
31. Fee
(MM/DD/CCYY)
or Letter(s)
Surface
Code
Cavity
System
1
2
3
4
5
6
7
8
9
10
MISSING TEETH INFORMATION
Permanent
Primary
32. Other
9 10 11 12 13 14 15 16
A B C D E
F G H
I
J
Fee(s)
34. (Place an 'X' on each missing tooth)
32
31
30
29
28
27
26
25
24 23
22 21
20 19 18
17
T
S R
Q
P
O
N M
L
K 33.Total Fee
35. Remarks
AUTHORIZATIONS
ANCILLARY CLAIM/TREATMENT INFORMATION
36. I have been informed of the treatment plan and associated fees. I agree to be responsible for all
38. Place of Treatment
39. Number of Enclosures (00 to 99)
charges for dental services and materials not paid by my dental benefit plan, unless prohibited by law, or
Radiograph(s) Oral Image(s)
Model(s)
the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of
Provider’s Office
Hospital
ECF
such charges. To the extent permitted by law, I consent to your use and disclosure of my protected health
information to carry out payment activities in connection with this claim.
40. Is Treatment for Orthodontics?
41. Date Appliance Placed (MM/DD/CCYY)
X
No (Skip 41-42)
Yes
(Complete 41-42)
Patient/Guardian signature
Date
42. Months of Treatment
43. Replacement of Prosthesis?
44. Date Prior Placement (MM/DD/CCYY)
Remaining
37. I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to the below named
No
Yes (Complete 44)
dentist or dental entity.
45. Treatment Resulting from
Occupational illness/injury
Auto accident
Other accident
Subscriber signature
46. Date of Accident (MM/DD/CCYY)
47. Auto Accident State
BILLING DENTIST OR DENTAL ENTITY (Leave blank if dentist or dental entity is not submitting
TREATING DENTIST AND TREATMENT LOCATION INFORMATION
claim on behalf of the patient or insured/subscriber)
53. I hereby certify that the procedures as indicated by date are in progress (for procedures that require multiple
visits) or have been completed.
48. Name, Address, City, State, Zip Code
Signed (Treating Dentist)
54. NPI
55. License Number
56. Address, City, State, Zip Code
56A. Provider
Specialty Code
49. NPI
50. License Number
51. SSN or TIN
52. Phone
(
)
–
52A. Additional
57. Phone
58. Additional
Number
Provider ID
©2006 American Dental Association
To Reorder call 1-800-947-4746
J400 (Same as ADA Dental Claim Form – J401, J402, J403, J404)
or go online at www.adacatalog.org
Comprehensive completion instructions for the ADA Dental Claim Form are found in Section 4 of the ADA Publication titled CDT-2007/2008. Five relevant extracts from that section follow:
GENERAL INSTRUCTIONS
A. The form is designed so that the name and address (Item 3) of the third-party payer receiving the claim (insurance company/dental benefit plan) is visible in a standard #10 window envelope. Please fold the form using the ‘tick-marks’ printed in the margin.
B. In the upper-right of the form, a blank space is provided for the convenience of the payer or insurance company, to allow the
assignment of a claim or control number.
C. All Items in the form must be completed unless it is noted on the form or in the following instructions that completion is not required.
D. When a name and address field is required, the full name of an individual or a full business name, address and zip code must be entered.
E. All dates must include the four-digit year.
F. If the number of procedures reported exceeds the number of lines available on one claim form, the remaining procedures must be
listed on a separate, fully completed claim form.
COORDINATION OF BENEFITS (COB)
When a claim is being submitted to the secondary payer, complete the form in its entirety and attach the primary payer’s Explanation of Benefits (EOB) showing the amount paid by the primary payer. You may indicate the amount the primary carrier paid in the “Remarks” field (Item # 35).
NATIONAL PROVIDER IDENTIFIER (NPI)
49 and 54 NPI (National Provider Indentifier): This is an identifier assigned by the Federal government to all providers considered to be HIPAA covered entities. Dentists who are not covered entities may elect to obtain an NPI at their discretion, or may be enumerated if required by a participating provider agreement with a third-party payer or applicable state law/regulation. An NPI is unique to an individual dentist (Type 1 NPI) or dental entity (Type 2 NPI), and has no intrinsic meaning. Additional information on NPI and enumeration can be obtained from the ADA’s Internet Web Site: www.ada.org/goto/npi
ADDITIONAL PROVIDER IDENTIFIER
52A and 58 Additional Provider ID: This is an identifier assigned to the billing dentist or dental entity other than a Social Security Number (SSN) or Tax Identification Number (TIN). It is not the provider’s NPI. The additional identifier is sometimes referred to as a Legacy Identifier (LID). LIDs may not be unique as they are assigned by different entities (e.g., third-party payer; Federal government). Some Legacy IDs have an intrinsic meaning.
PROVIDER SPECIALTY CODES
56A Provider Specialty Code: Enter the code that indicates the type of dental professional who delivered the treatment. Available codes describing treating dentists are listed below. The general code listed as ‘Dentist’ may be used instead of any other dental practitioner code.
Category / Description Code
Dentist
A dentist is a person qualified by a doctorate in dental surgery (D.D.S)
122300000X
or dental medicine (D.M.D.) licensed by the state to practice dentistry,
and practicing within the scope of that license.
General Practice
1223G0001X
Dental Specialty (see following list)
Various
Dental Public Health
1223D0001X
Endodontics
1223E0200X
Orthodontics
1223X0400X
Pediatric Dentistry
1223P0221X
Periodontics
1223P0300X
Prosthodontics
1223P0700X
Oral & Maxillofacial Pathology
1223P0106X
Oral & Maxillofacial Radiology
1223D0008X
Oral & Maxillofacial Surgery
1223S0112X
Dental provider taxonomy codes listed above are a subset of the full code set that is posted at:
www.wpc-edi.com/codes/taxonomy
Should there be any updates to ADA Dental Claim Form completion instructions, the updates will be posted on the ADA’s web site at:
www.ada.org/goto/dentalcode
To accurately fill out the ADA Dental Claim Form, careful attention to detail is necessary. This form is a critical component for ensuring that dental services provided are appropriately billed to and reimbursed by the insurance company. It encompasses various sections including header information, policyholder/subscriber and insurance company information, patient details, and a record of services provided. Follow these steps to complete the form correctly.
The correctly completed ADA Dental Claim Form plays a vital role in the dental billing process, facilitating timely and accurate reimbursement for dental services rendered. Moreover, it assists in maintaining transparent communication between dental practices, patients, and insurance companies. Once the form is filled out, review all sections for accuracy before submission to the relevant insurance company for processing.
What is the ADA Dental Claim Form used for?
The ADA Dental Claim Form is widely used by dental practices to submit dental claims to insurance companies or dental benefit plans. It facilitates the process for dental offices to obtain payment for services provided to insured patients. This document covers several key pieces of information, including details of the dental service(s) rendered, patient and policyholder information, and insurance coverage details.
How do you obtain an ADA Dental Claim Form?
Dental practices can obtain ADA Dental Claim Forms by purchasing them through the American Dental Association’s website at www.adacatalog.org, or by calling 1-800-947-4746. These forms are specifically designed to meet the requirements of dental claims processing and ensure compatibility with the systems used by dental insurance companies.
Is it necessary to fill out all sections of the ADA Dental Claim Form?
Yes, it is essential to complete all required sections of the ADA Dental Claim Form unless indicated otherwise. Incomplete forms may lead to processing delays or denials of payment. Some sections can be skipped only if they do not apply to the specific situation, such as sections dealing with other coverage if the patient does not have secondary insurance.
What should be included in the "Record of Services Provided" section?
In the "Record of Services Provided" section, dental practitioners should include detailed information about the services rendered during the patient's visit. This includes the date of the procedure, tooth number(s), procedure codes, descriptions, and fees. If the number of procedures exceeds the space available on the form, additional procedures should be listed on a separate, fully completed claim form.
How can a dental practice submit the ADA Dental Claim Form to an insurance company?
The ADA Dental Claim Form can be submitted to insurance companies electronically or by mail. When submitting by mail, it's important to fold the form as indicated by the tick marks printed in the margin so that the address of the insurance company is visible in a #10 window envelope. Electronic submissions must follow the payer’s guidelines.
What is the importance of the National Provider Identifier (NPI) on the ADA Dental Claim Form?
The National Provider Identifier (NPI) is a critical identifier that the federal government assigns to all healthcare providers, including dentists. It must be included on the ADA Dental Claim Form to ensure the form is processed efficiently. The NPI helps in identifying the dental provider and is required for all Electronic Health Records (EHR) and insurance transactions.
What information is required for "Other Coverage"?
When a patient has other dental or medical coverage, detailed information about the secondary insurance plan must be provided. This includes the name of the policyholder for the other insurance, their date of birth, gender, ID number, and the insurance company’s name and address. If the patient does not have other coverage, this section can be skipped.
Can a patient submit an ADA Dental Claim Form directly to their insurance company?
While it is more common for the dental care provider to submit the claim on behalf of the patient, patients can submit the ADA Dental Claim Form directly to their insurance company if necessary. In such cases, it's vital to ensure that the form is fully completed and accompanied by any required attachments, such as detailed treatment records or Explanation of Benefits (EOB) if coordinating benefits.
Filling out the ADA Dental Claim Form can be tricky, and making mistakes can delay the processing of your claim. Here are ten common mistakes people make:
Forgetting to mark the Type of Transaction box. This section is crucial as it informs the insurance company about the nature of your submission.
Leaving the Predetermination/Preauthorization Number blank, if applicable. This number is essential for services that require pre-approval.
Incorrectly filling out the Policyholder/Subscriber Information. This information helps the insurance company identify the correct policy.
Not specifying if there is Other Dental or Medical Coverage. This detail is vital for coordinating benefits if the patient is covered under more than one plan.
Omitting the Relationship to Policyholder/Subscriber. This indicates who the patient is in relation to the policyholder, affecting coverage details.
Providing incomplete Patient Information. Every detail, from name to address, is necessary for processing the claim accurately.
Leaving out Missing Teeth Information. This is crucial information for treatment plans and coverage determination.
Skipping the Record of Services Provided section. This includes procedure dates, descriptions, and fees, which are all essential for claim evaluation.
Forgetting to sign the Authorization section. Without the patient's or guardian's signature, processing the claim can be delayed or denied.
Not utilizing the Remarks field appropriately. This field is helpful for providing additional information that can expedite claim processing.
It's always a good idea to double-check your form before submission to ensure all necessary information is correctly provided. This can help avoid delays and ensure your claim is processed smoothly.
When processing or submitting an ADA Dental Claim Form, specific additional forms and documents are commonly required to ensure comprehensive and precise handling of the claim. These supplementary materials aid in providing a full picture of the treatment, justification for the services, and the necessary information for insurance processing. Below is an overview of other forms and documents often used alongside the ADA Dental Claim Form.
Together with the ADA Dental Claim Form, these documents form a comprehensive package that allows dental professionals to communicate effectively with insurance companies. This ensures that all the necessary information is available for the processing and evaluation of claims, ultimately leading to an efficient reimbursement process for the patient and the dental practice.
The AMA Medical Claim Form is similar because it collects detailed patient information, insurance details, and specific services provided, similar to the ADA Dental Claim Form which also requires comprehensive data about the patient, services rendered, policyholder information, and other coverage details to process dental claims.
The Health Insurance Claim Form (HCFA-1500) parallels the ADA Dental Claim Form in its purpose to facilitate insurance claims, requiring provider and patient information, diagnosis codes, service codes, and billing information, ensuring accurate processing and payment of health care services.
The Vision Care Claim Form shares similarities with the ADA form in that it requires the submission of patient demographics, insurance policy details, and specific services received — in this case, related to vision care — for the purpose of insurance reimbursement.
The Workers' Compensation Claim Form is akin to the ADA Dental Claim Form due to its necessity in reporting specific information about an incident or treatment relating to a work-related injury, including patient information, employer details, and medical services provided, for compensation purposes.
The Pharmacy Benefit Management (PBM) Claim Form is comparable as it also collects essential information for the processing of claims, specifically related to prescription medications, including patient information, insurance details, and prescribed pharmaceuticals, paralleling the service-specific data collection seen in the ADA Dental Claim Form.
The Automobile Insurance Medical Claim Form bears resemblance in its structured approach to collecting detailed information about the patient (or claimant), the nature of the injury or treatment received, and relevant insurance information, targeting the processing of claims related to auto accident-related medical care.
Filling out the ADA Dental Claim form accurately is crucial to ensure prompt and correct processing by insurance companies. Here are some important do's and don'ts to consider:
When dealing with the ADA Dental Claim Form, understanding its complexities is crucial. However, there are common misconceptions that often lead to confusion and mistakes. Let's unravel these misconceptions to ensure accurate and effective handling of dental claims.
Many believe that every field in the ADA Dental Claim Form must be completed for every submission. This isn't always the case. While thoroughness is important, certain sections are specific to predetermined conditions or types of coverage and need only be completed when applicable. For example, the section regarding other dental or medical coverage only needs to be filled out if there is additional insurance involved.
Another common misunderstanding is that the form is exclusively used for insurance reimbursement purposes. In reality, this form also facilitates the request for predetermination/preauthorization of services. It serves a dual purpose, not only documenting services rendered for reimbursement but also acting as a communication tool with the insurance provider to authorize a treatment plan.
While the National Provider Identifier (NPI) is a critical component of the form, it's not the only identifier that can be used. Depending on the scenario, an Additional Provider Identifier (Item #52A for the billing dentist or #58 for additional providers) might be required, especially in circumstances where the NPI does not apply or an additional layer of identification is necessary.
When a patient has dual coverage, accurately completing the Coordination of Benefits section becomes essential. This misconception often leads to delays or denials. By attaching the primary payer’s Explanation of Benefits (EOB) and documenting the amount paid by the primary payer, the secondary insurer can properly assess and process the claim.
Understanding these misconceptions about the ADA Dental Claim Form can greatly enhance the efficiency and accuracy of dental claim processing. Being well-informed ensures smoother interactions with insurance companies and contributes to a more streamlined claims experience for both providers and patients.
When navigating the complexities of the ADA Dental Claim Form, understanding its structure and requirements is crucial for accurate and timely processing. Here are key takeaways to ensure that you fill out and use the form effectively:
Understanding and adhering to these key points when completing the ADA Dental Claim Form not only assists in the smooth processing of dental claims but also minimizes the risk of errors or delays in insurance reimbursement. As intricate as insurance paperwork may seem, a systematic approach to completing and reviewing each section of the claim form can greatly simplify the process.
Ero Signature - This form is used by taxpayers to authorize an eligible person, such as an attorney or certified public accountant, to handle their tax affairs.
Printable Home Daycare Child Care Receipt Template - A practical tool for child care providers to formalize the receipt of payments from families.
Shelter Information Form Hr3037 - It serves as a documentation foundation for those entering into new rental agreements, especially in securing financial assistance for housing transitions.