Guardian Dental Claim Form PDF Details

Guardian dental claim form is an important document for both the patient and the dentist. The form helps to track services provided, payments made, and other important information related to the patient's dental care. It is also used to submit insurance claims and receive reimbursement for services. Learn more about how to properly complete a Guardian dental claim form in this article.

Listed here, you will find a number of particulars about guardian dental claim form PDF. Our suggestion is that you read through this info before you start fiddling with the file.

QuestionAnswer
Form NameGuardian Dental Claim Form
Form Length2 pages
Fillable?Yes
Fillable fields203
Avg. time to fill out20 min 35 sec
Other namesguardian anytime dental provider login, guardian dental login member, guardian dentalguard login, guardiananytime forms

Form Preview Example

<![endif]>fold

<![endif]>fold

Dental Claim Form

HEADER INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Guardian

 

 

 

 

 

 

 

 

 

 

 

1. Type of Transaction (Mark all applicable boxes)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Individual Dental Claims

 

 

 

 

 

Statement of Actual Services

 

 

 

Request for Predetermination/Preauthorization

 

 

 

 

 

 

 

 

 

 

 

 

PO Box 254888

 

 

 

 

 

 

 

 

 

EPSDT / Title XIX

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sacramento, CA 95865-9005

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

POLICYHOLDER/SUBSCRIBER INFORMATION (For Insurance Company Named in #3)

 

 

2. Predetermination/Preauthorization Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 (Mark applicable box and complete items 5-11. If none, leave blank.)

 

16. Plan/Group Number

 

 

 

17. Employer Name

 

 

 

 

 

 

 

 

 

 

 

4. Dental?

 

 

Medical?

 

(If both, complete 5-11 for dental only.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. Name of Policyholder/Subscriber in # 4 (Last, First, Middle Initial, Suffix)

 

 

 

 

 

 

Patient Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18. Relationship to Policyholder/Subscriber in #12 Above

 

 

 

 

 

19. Reserved For Future

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Self

 

Spouse

 

Dependent Child

 

Other

 

Use

 

<![endif]>fold

 

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

 

7. Gender

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

29a. Diag.

29b.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

of Oral

Tooth

 

 

 

 

 

 

 

 

 

 

 

 

 

30. Description

 

 

 

 

31. Fee

 

 

 

 

(MM/DD/CCYY)

 

 

 

 

 

 

or Letter(s)

 

 

 

Surface

 

 

Code

Pointer

Qty.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cavity

System

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

33. Missing Teeth Information

(Place an “X” on each missing tooth.)

 

 

 

 

 

34. Diagnosis Code List Qualifier

 

 

 

 

( ICD-9 = B; ICD-10 = AB )

 

 

 

 

31a. Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fee(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

2

3

4

5

6

7

 

8

9

10

11

12

13

14

15

16

 

34a. Diagnosis Code(s)

A _________________

C _________________

 

 

 

 

 

 

 

 

 

 

 

 

 

32

31

30

29

28

27

26

 

25

24

23

22

21

20

19

18

17

 

(Primary diagnosis in “A”)

B _________________

D _________________

32. Total Fee

 

$0.00

<![endif]>fold

 

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

n

(e.g. 11=office; 22=O/P Hospital)

39. Enclosures (Y or N)

 

 

 

 

charges for dental services and materials not paid by my dental benefit plan, unless prohibited by

 

 

(Use “Place of Service Codes for Professional Claims”)

 

 

 

 

 

 

 

 

 

 

 

 

law, or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

or a portion of such charges. To the extent permitted by law, I consent to your use and disclosure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

40. Is Treatment for Orthodontics?

 

 

 

 

 

 

 

41. Date Appliance Placed (MM/DD/CCYY)

 

 

 

of my protected health information to carry out payment activities in connection with this claim.

 

 

 

 

 

 

 

 

 

 

 

 

No (Skip 41-42)

 

Yes (Complete 41-42)

 

 

 

 

 

 

 

 

 

 

 

X _____________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient/Guardian Signature

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

42. Months of Treatment

43. Replacement of Prosthesis

 

44. Date of Prior Placement (MM/DD/CCYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

Yes (Complete 44)

 

 

 

 

 

 

 

 

 

37. I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

to the below named 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

TREATING DENTIST AND TREATMENT LOCATION INFORMATION

 

 

 

submitting 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

 

 

 

 

 

 

 

©2012 American Dental Association

To reorder call 800.947.4746

J430D (Same as ADA Dental Claim Form – J430, J431, J432, J433, J434)

or go online at adacatalog.org

The following information highlights certain form completion instructions. Comprehensive ADA Dental Claim Form completion instructions are printed in the CDT manual. Any updates to these instructions will be posted on the ADA’s web site (ADA.org).

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 #9 window envelope (window to the left). Please fold the form using the ‘tick-marks’ printed in the margin.

B.Complete all items unless noted otherwise on the form or in the CDT manual’s instructions.

C.Enter the full name of an individual or a full business name, address and zip code when a name and address field is required.

D.All dates must include the four-digit year.

E.If the number of procedures reported exceeds the number of lines available on one claim form, list the remaining procedures on a separate, fully completed claim form.

COORDINATION OF BENEFITS (COB)

When a claim is being submitted to the secondary payer, complete the entire form and attach the primary payer’s Explanation of Benefits (EOB) showing the amount paid by the primary payer. You may also note the primary carrier paid amount in the “Remarks” field (Item 35). There are additional detailed completion instructions in the CDT manual.

DIAGNOSIS CODING

The form supports reporting up to four diagnosis codes per dental procedure. This information is required when the diagnosis may affect claim adjudication when specific dental procedures may minimize the risks associated with the connection between the patient’s oral and systemic health conditions. Diagnosis codes are linked to procedures using the following fields:

Item 29a – Diagnosis Code Pointer (“A” through “D” as applicable from Item 34a)

Item 34 – Diagnosis Code List Qualifier (B for ICD-9-CM; AB for ICD-10-CM)

Item 34a – Diagnosis Code(s) / A, B, C, D (up to four, with the primary adjacent to the letter “A”)

PLACE OF TREATMENT

Enter the 2-digit Place of Service Code for Professional Claims, a HIPAA standard maintained by the Centers for Medicare and Medicaid Services. Frequently used codes are:

11 = Office; 12 = Home; 21 = Inpatient Hospital; 22 = Outpatient Hospital; 31 = Skilled Nursing Facility; 32 = Nursing Facility

The full list is available online at “www.cms.gov/PhysicianFeeSched/Downloads/Website_POS_database.pdf”

PROVIDER SPECIALTY

This code is entered in Item 56a and indicates the type of dental professional who delivered the treatment. The general code listed as “Dentist” may be used instead of any of the other codes.

Category / Description Code

Code

Dentist

122300000X

A dentist is a person qualified by a doctorate in dental surgery (D.D.S.)

 

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

Provider taxonomy codes listed above are a subset of the full code set that is posted at “www.wpc-edi.com/codes/taxonomy”

How to Edit Guardian Dental Claim Form Online for Free

Writing the guardiananytime forms form is simple with this PDF editor. Stick to these steps to prepare the document right away.

Step 1: The webpage includes an orange button saying "Get Form Now". Click it.

Step 2: At this point, it is possible to change the guardiananytime forms. Our multifunctional toolbar helps you include, get rid of, transform, highlight, as well as undertake similar commands to the content material and areas inside the file.

Fill in the guardiananytime forms PDF by entering the data meant for each part.

stage 1 to completing guardiananytime dental provider login

Remember to fill in the dof, Remarks, ICDBICDAB, aOtherFees, TotalFee, fod, XPatientGuardianSignatureDate, EnclosuresYorN, IsTreatmentforOrthodontics, DateAppliancePlacedMMDDCCYY, NoSkip, YesComplete, MonthsofTreatment, ReplacementofProsthesisYesComplete, and TreatmentResultingfrom box with the requested data.

guardiananytime dental provider login dof, Remarks, ICDBICDAB, aOtherFees, TotalFee, fod, XPatientGuardianSignatureDate, EnclosuresYorN, IsTreatmentforOrthodontics, DateAppliancePlacedMMDDCCYY, NoSkip, YesComplete, MonthsofTreatment, ReplacementofProsthesisYesComplete, and TreatmentResultingfrom fields to fill

You may be asked to write down the information to let the system complete the segment NameAddressCityStateZipCode, multiplevisitsorhavebeencompleted, LicenseNumberaProviderSpecialtyCode, NPI, PhoneNumber, LicenseNumber, SSNorTIN, aAdditionalProviderID, PhoneNumber, Additional, and ProviderID.

step 3 to filling out guardiananytime dental provider login

Step 3: Hit the "Done" button. Next, it is possible to transfer the PDF file - download it to your electronic device or send it by using email.

Step 4: You should make as many copies of your document as possible to avoid possible misunderstandings.

Watch Guardian Dental Claim Form Video Instruction

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