The Ada Dental Claim Form is a standardized document used to submit dental claims to insurance companies or dental benefit plans. This form captures essential information about the patient, the policyholder, and the services provided, ensuring that claims are processed efficiently. Understanding how to complete this form correctly can streamline the reimbursement process and minimize delays in receiving benefits.
The ADA Dental Claim Form serves as a vital tool for dentists and dental practices when submitting claims to insurance companies. This comprehensive document captures essential information regarding the patient, the services provided, and the associated costs. It includes sections for header information, policyholder details, patient information, and a record of services rendered. Each section requires specific data, such as the type of transaction—whether it’s a statement of actual services or a request for preauthorization. Additionally, the form asks for details about the insurance coverage, including the policyholder's name, the insurance company's information, and any other relevant coverage. The record of services section is particularly important, as it outlines the procedures performed, the dates they occurred, and the fees charged. Furthermore, the form includes authorizations for treatment and consent for the use of protected health information. By ensuring that all required fields are completed accurately, dental professionals can facilitate smoother claims processing and improve reimbursement outcomes.
What is the purpose of the ADA Dental Claim Form?
The ADA Dental Claim Form is used to submit claims for dental services to insurance companies or dental benefit plans. It provides a standardized way for dental providers to report services rendered and request payment for those services. The form includes essential information about the patient, the policyholder, and the specific dental procedures performed.
How do I fill out the header information section?
In the header information section, mark all applicable boxes to indicate the type of transaction. You may need to provide a predetermination or preauthorization number if applicable. Include the policyholder's name, address, and the insurance company's details. Ensure that all information is accurate to avoid delays in processing your claim.
What should I include in the patient information section?
In the patient information section, provide the patient's name, date of birth, gender, and relationship to the policyholder. Include the patient's ID or account number assigned by the dentist. If the patient is a dependent, make sure to indicate their relationship to the policyholder clearly.
What if the patient has other dental or medical coverage?
If the patient has other dental or medical coverage, you must complete sections 5-11 of the form. This includes providing the name of the policyholder for the other coverage, their relationship to the patient, and details about the other insurance company or dental benefit plan.
How do I report the services provided?
In the record of services provided section, list each procedure performed, including the date, area, tooth number, and procedure description. Be sure to include the corresponding fee for each service. If there are more procedures than available lines on the form, use an additional claim form to report the remaining services.
What are the requirements for submitting a claim for orthodontics?
If the treatment involves orthodontics, indicate this in the appropriate section. You will need to provide the date the appliance was placed and the number of months of treatment. Complete any additional questions related to orthodontic services as required by the form.
How do I authorize payment to the dentist?
To authorize payment directly to the dentist, sign the authorization section of the form. This allows the insurance company to pay the dental benefits directly to the dentist or dental entity, rather than to the policyholder. Ensure that you provide the dentist's name and address in the billing section for proper processing.
What should I do if my claim is being submitted to a secondary payer?
If submitting a claim to a secondary payer, complete the form in its entirety and attach the primary payer’s Explanation of Benefits (EOB). This document shows the amount paid by the primary payer. You can also note the amount paid in the remarks section of the claim form.
Where can I find additional information about completing the ADA Dental Claim Form?
For comprehensive instructions on completing the ADA Dental Claim Form, refer to the ADA Publication titled CDT-2007/2008. Additional updates and resources can be found on the ADA's website, which provides guidance on the latest requirements and best practices for claim submissions.
When filling out and using the ADA Dental Claim Form, there are several important aspects to keep in mind. Here are key takeaways that can help ensure a smooth process:
By adhering to these guidelines, you can enhance the likelihood of a successful claim submission and avoid unnecessary complications.
1. The ADA Dental Claim Form is only for dental insurance claims. Many believe this form is exclusive to dental claims. However, it can also be used for preauthorization requests and EPSDT claims.
2. All fields on the form must be filled out. While it’s important to provide comprehensive information, some fields are optional. If a section does not apply, it can be left blank.
3. The form can be submitted without the patient's signature. A valid signature from the patient or guardian is necessary to authorize the submission of the claim and the use of their health information.
4. The National Provider Identifier (NPI) is not important. The NPI is crucial for identifying healthcare providers in the claim process. It helps ensure accurate processing and payment.
5. You can submit multiple claims on one form. Each claim must be submitted on a separate form if the number of procedures exceeds the available lines on one claim.
6. The ADA Dental Claim Form does not require a date of birth. The date of birth is essential for both the policyholder and the patient. It helps verify identities and coverage.
7. The form is only for adults. The ADA Dental Claim Form can be used for patients of all ages, including children. Information specific to dependents must be provided when applicable.
8. You can use any format for the dates. All dates must be formatted as MM/DD/CCYY. This standardization is necessary for proper processing.
9. The form is the same for all insurance companies. Different insurance companies may have specific requirements. Always check with the insurance provider for any additional information needed.
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
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Incomplete Information: One common mistake is failing to fill out all required fields on the form. Each section, from policyholder details to patient information, must be fully completed. Omitting even a single piece of information can delay processing and lead to claim rejection.
Incorrect Dates: Another frequent error involves the format of dates. Dates must be entered in the MM/DD/CCYY format. Inaccurate or improperly formatted dates can cause confusion and may result in the claim being processed incorrectly.
Missing Signatures: Claims submitted without the necessary signatures are often returned. Both the patient or guardian and the treating dentist must sign the form. Failure to secure these signatures can lead to delays in payment.
Neglecting Coordination of Benefits: For individuals with multiple insurance plans, it is crucial to indicate any other coverage. Not completing the Coordination of Benefits section can prevent the claim from being processed correctly, especially if there is a primary payer involved.
Inaccurate Provider Information: Lastly, entering incorrect information about the treating dentist can lead to issues. This includes not providing the National Provider Identifier (NPI) or using an outdated address. Accurate provider details are essential for proper claim processing and reimbursement.
The ADA Dental Claim Form shares similarities with the CMS-1500 form, which is used for submitting medical claims to insurance companies. Both forms require detailed information about the patient, policyholder, and the services rendered. They collect data such as names, addresses, and identification numbers, ensuring that the insurance provider can accurately process the claim. Each form also includes sections for documenting the services provided, allowing for a clear understanding of the treatment and associated costs. Both documents aim to facilitate reimbursement for healthcare services, although they cater to different types of providers.
Another document comparable to the ADA Dental Claim Form is the UB-04 form, commonly used for institutional healthcare claims. Like the ADA form, the UB-04 captures essential information about the patient and the services provided. It includes fields for patient demographics, service dates, and billing codes. The UB-04 is primarily utilized by hospitals and other healthcare facilities, while the ADA form is specific to dental practices. Despite these differences, both forms serve the same purpose of ensuring that healthcare providers receive payment for their services from insurance companies.
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The Health Insurance Claim Form (HICF) is also similar to the ADA Dental Claim Form. This form is used by healthcare providers to submit claims for reimbursement from Medicare and other health insurance programs. Both forms require comprehensive details regarding the patient, the provider, and the services rendered. They also include sections for documenting the specific procedures performed, allowing for a clear breakdown of costs. The HICF is tailored for a broader range of medical services, while the ADA form focuses specifically on dental care, yet both aim to streamline the claims process for efficient reimbursement.
Lastly, the Dental Claim Attachment Form is another document that parallels the ADA Dental Claim Form. This form is often used in conjunction with the ADA form to provide additional information or documentation required by the insurance company. Both forms collect similar patient and treatment information, ensuring that the insurance provider has all necessary details to process the claim. The Dental Claim Attachment Form serves as a supplementary document that enhances the primary claim, similar to how other forms provide supporting data to facilitate payment for services rendered.