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Fill in a Valid Ada Dental Claim Form

The Ada Dental Claim Form is a standardized document used by dental professionals to submit claims for reimbursement from dental benefit plans. This form captures essential information about the patient, the policyholder, and the specific dental services provided. Understanding how to accurately complete this form is crucial for ensuring timely processing and payment of dental claims.

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Document Sample

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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#)

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

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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

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

of Oral

Tooth

30. Description

31. Fee

(MM/DD/CCYY)

or Letter(s)

Surface

Code

Cavity

System

MISSING TEETH INFORMATION

Permanent

Primary

32. Other

9 10 11 12 13 14 15 16

A B C D E

F G H

Fee(s)

34. (Place an 'X' on each missing tooth)

24 23

22 21

20 19 18

S R

N M

K 33.Total Fee

35. Remarks

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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)

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

Yes (Complete 44)

dentist or dental entity.

45. Treatment Resulting from

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

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

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

Document Information

Fact Name	Details
Transaction Types	The form allows for multiple transaction types, including Statement of Actual Services, Request for Predetermination/Preauthorization, and EPSDT/Title XIX.
Policyholder Information	Section 12 requires the policyholder's name, address, and date of birth.
Insurance Company Details	Section 3 captures the name and address of the insurance company or dental benefit plan.
Other Coverage	If there is other dental or medical coverage, Sections 5-11 must be completed.
Patient Information	Sections 18-23 gather information about the patient, including relationship to the policyholder and date of birth.
Record of Services	Sections 24-33 detail the procedures performed, including dates, tooth numbers, and fees.
Authorization Statement	Section 36 includes a statement where the patient agrees to be responsible for charges not covered by their dental plan.
National Provider Identifier (NPI)	Sections 49 and 54 require the NPI for the billing dentist or dental entity.
Provider Specialty Code	Section 56A asks for a code indicating the type of dental professional who provided treatment.
State-Specific Regulations	Each state may have specific laws governing the use of the ADA Dental Claim Form, particularly regarding the coordination of benefits.

Ada Dental Claim - Usage Guidelines

Filling out the ADA Dental Claim form is an important step in ensuring that dental services are billed correctly to your insurance provider. This process involves providing accurate information about the patient, policyholder, and the services rendered. Careful attention to detail will help avoid delays in processing the claim.

Begin by marking the appropriate boxes under Type of Transaction (Item 1). Indicate whether this is a Statement of Actual Services, a Request for Predetermination/Preauthorization, or related to EPSDT/Title XIX.
If applicable, fill in the Predetermination/Preauthorization Number (Item 2).
Under Policyholder/Subscriber Information, provide the full name, address, city, state, and zip code of the policyholder (Item 12).
In the Insurance Company/Dental Benefit Plan Information section, fill in the company/plan name, address, city, state, and zip code (Item 3).
Complete the Date of Birth (Item 13) and Gender (Item 14) fields for the policyholder/subscriber.
Enter the Policyholder/Subscriber ID (Item 15), which can be either the Social Security Number or another ID number.
If there is other dental or medical coverage, indicate Yes or No (Item 4). If yes, complete Items 5-11.
For other coverage, provide the name of the policyholder/subscriber (Item 5) and their details.
Proceed to the Patient Information section. Specify the relationship to the policyholder/subscriber (Item 18) and the patient’s student status (Item 19).
Fill in the patient's Date of Birth (Item 6) and Gender (Item 7).
Complete the Patient ID/Account # (Item 23) assigned by the dentist.
In the Record of Services Provided section, enter the procedure date (Item 24) and details about the treatment, including area, tooth numbers, procedure codes, and fees (Items 25-31).
If applicable, indicate any Missing Teeth Information (Item 32) and total fees (Item 33).
Review the Authorizations section (Items 36-45). Sign and date where required.
Complete the Billing Dentist or Dental Entity section (Items 48-56), providing the necessary identifiers and contact information.
Finally, ensure that all required fields are completed accurately and clearly, and fold the form as indicated for submission.

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Dos and Don'ts

When filling out the ADA Dental Claim form, it's essential to approach the task with care. Here’s a list of five things you should and shouldn't do:

Do complete all required fields accurately, including names, addresses, and dates.
Don't leave any mandatory sections blank; incomplete forms can delay processing.
Do use the correct format for dates, ensuring to include the four-digit year.
Don't forget to sign the form where indicated; your signature is crucial for authorization.
Do attach any necessary documents, such as the primary payer's Explanation of Benefits, if applicable.

By following these guidelines, you can help ensure a smoother claims process. Attention to detail will save time and prevent unnecessary complications.

Common mistakes

Leaving Required Fields Blank: Many people overlook mandatory fields. Each section must be filled out completely unless specified otherwise. Missing information can lead to delays or denials of claims.
Incorrect Dates: Failing to use the four-digit year for dates is a common mistake. This can create confusion and may result in processing errors.
Not Indicating Other Coverage: If there is other dental or medical insurance, it’s crucial to indicate this on the form. Skipping this step can complicate the claim process.
Inaccurate Patient Information: Providing incorrect details about the patient, such as the name or relationship to the policyholder, can cause significant issues. Double-checking this information is essential.
Improper Use of Codes: Using the wrong procedure or specialty codes can lead to claim denials. Ensure that the correct codes are used for the services rendered.
Neglecting to Sign: Forgetting to sign the form is a frequent oversight. Without a signature, the claim cannot be processed, leading to unnecessary delays.

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