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.
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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. |
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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. |
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E. All dates must include the four-digit year. |
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F. If the number of procedures reported exceeds the number of lines available on one claim form, the remaining procedures must be |
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listed on a separate, fully completed claim form. |
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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 |
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Dentist |
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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, |
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and practicing within the scope of that license. |
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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