Guardian Dental Claim Form – Fill Out and Use This PDF

The Guardian Dental Claim Form is a document that you can use to file for dental care. It's important to have the correct information on it so that your claim goes smoothly and without delay.

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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.

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Question	Answer
Form Name	Guardian Dental Claim Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	guardian anytime dental provider login, guardian dental login member, guardian dental member login, guardian dental insurance login

Form Preview Example

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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#)

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

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

7. Gender

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

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)

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

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)

34a. Diagnosis Code(s)

A _________________

C _________________

(Primary diagnosis in “A”)

B _________________

D _________________

32. Total Fee

$0.00

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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

(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)

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”

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stage 1 to completing guardian anytime dental provider login

Remember to fill in the Missing Teeth Information Place, Diagnosis Code List Qualifier, ICD B ICD AB, a Diagnosis Codes, Primary diagnosis in A, a Other Fees, Total Fee, d o f, Remarks, AUTHORIZATIONS, I have been informed of the, charges for dental services and, X PatientGuardian Signature Date, f o d, and ANCIllARy ClAImTREATmENT box with the requested data.

guardian anytime dental provider login Missing Teeth Information Place, Diagnosis Code List Qualifier, ICD B ICD AB, a Diagnosis Codes, Primary diagnosis in A, a Other Fees, Total Fee, d o f, Remarks, AUTHORIZATIONS, I have been informed of the, charges for dental services and, X PatientGuardian Signature Date, f o d, and ANCIllARy ClAImTREATmENT fields to fill

You may be asked to write down the information to let the system complete the segment BIllINg DENTIST OR DENTAl ENTITy, Name Address City State Zip Code, I hereby certify that the, multiple visits or have been, X Signed Treating Dentist Date, NPI, Address City State Zip Code, License Number, a Provider Specialty Code, NPI, License Number, SSN or TIN, Phone, Number, and a Additional Provider ID.

step 3 to filling out guardian anytime dental provider login

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