Ada Dental Claim Form – Fill Out and Use This PDF

Ada Dental Claim Form is a document that describes the services provided by a dental provider and provides information about how to claim reimbursement.

We make sure it is convenient and secure to edit this form. Press the button below, and you can open your PDF document. Filling out current PDF form can be easily done with a mobile phone or laptop.

Get Form Now Download PDF

Ada Dental Claim Form first page preview

Ada Dental Claim Form PDF Details

The ADA Dental Claim Form is a form that is used to document dental treatment and procedures. It can be used for both reimbursement and personal use, such as insurance claims or creating documentation of work done. The form may vary depending on the country, but generally includes information about patient demographics, diagnosis, treatment details and so forth. There are many benefits to using this type of form in your practice--including the elimination of paperwork errors and ensuring you're following best practices for documentation with your patients. This blog post will offer guidelines for completing an ADA Dental Claim Form as well as provide examples from various countries (USA, Canada).

Below is the information in regards to the PDF you were seeking to fill out. It can tell you the length of time you will require to fill out ada dental claim form, what parts you need to fill in and a few further specific details.

Question	Answer
Form Name	Ada Dental Claim Form
Form Length	2 pages
Fillable?	Yes
Fillable fields	206
Avg. time to fill out	20 min 53 sec
Other names	american dental association dental claim form, ada form pdf, dental ada claim form, ada dental claim form 2019

12

Form Preview Example

<![endif]>fold

<![endif]>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

<![endif]>fold

6. Date of Birth (MM/DD/CCYY)

7. Gender

8. Policyholder/Subscriber ID (SSN or ID#)

Dependent Child

Other

M

F

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

Self

Spouse

Dependent

Other

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)

M

F

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

1

2

3

4

5

6

7

8

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

<![endif]>fold

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

Other

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

X

Occupational illness/injury

Auto accident

Other accident

Subscriber signature

Date

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

X

Signed (Treating Dentist)

Date

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

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	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

How to Edit Ada Dental Claim Form Online for Free

This PDF editor makes it easy to fill out the ada dental claim form 2019 document. You will be able to obtain the form effortlessly through using these simple actions.

Step 1: Choose the button "Get Form Here".

Step 2: Now it's easy to change the ada dental claim form 2019. The multifunctional toolbar will allow you to include, erase, adapt, and highlight text or perhaps conduct other sorts of commands.

Complete the next parts to complete the document:

part 1 to filling in american dental association dental claim form

You should submit the Tooth System, MISSING TEETH INFORMATION, Permanent, Primary, d o f, A B C D E, F G H I, T S R Q P, O N M L K, f o d, AUTHORIZATIONS, ANCILLARY CLAIM/ TREATMENT, Radio, graph, s Oral Image, s Model, s and Provider, s Office field with the appropriate information.

step 2 to entering details in american dental association dental claim form

You'll be requested to write down the data to help the platform fill in the part 52, A © 2006 American Dental Association, J, 400 (Same as ADA Dental Claim, To Reorder call 1, 800, 947, 4746 or, X Signed (Treating Dentist), Date, and 56, A

part 3 to filling out american dental association dental claim form

Step 3: Once you press the Done button, your finished form may be transferred to any of your devices or to email provided by you.

Step 4: Try to make as many copies of your document as you can to stay away from potential problems.

Watch Ada Dental Claim Form Video Instruction

Ada Dental Claim Form isn’t the one you’re looking for?

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .