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Fill Out Your Ada Dental Claim Form

The Ada Dental Claim Form is an essential document used to submit dental service claims to insurance providers. It gathers necessary information about the patient, policyholder, and services performed, ensuring the claims process runs smoothly. Completing this form accurately is important for prompt reimbursement for dental services rendered, so please fill it out properly by clicking the button below.

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Article Structure

The ADA Dental Claim Form serves as a crucial tool for both dental professionals and patients when it comes to submitting and processing dental claims through insurance providers. This comprehensive form gathers essential information ranging from the type of transaction—whether it's a statement of actual services rendered, a request for preauthorization, or related to a specific program like EPSDT—to the personal details of the policyholder and patient. In addition to basic identifiers such as names, addresses, and dates of birth, the form requires specifics about the dental procedure performed, including the date of service, procedure codes, and applicable fees. It also addresses any other insurance coverage the patient might have, ensuring that all relevant parties are aware and informed. Importantly, the form includes authorizations for payment and consent for the use of personal health information, emphasizing transparency and compliance with healthcare regulations. Each section is designed to facilitate a smooth claims process, making it imperative for complete and accurate filling to avoid delays in reimbursement.

Ada Dental Claim Example

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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

fold

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

Get Ada Dental Claim PDF Form

Form Characteristics

Fact Name	Details
Form Purpose	The ADA Dental Claim Form is used for submitting claims for dental services to insurance companies or dental benefit plans.
Required Information	All fields must be completed unless specified otherwise. This includes patient info, insurance details, and the procedure performed.
National Provider Identifier (NPI)	Dentists must include their NPI on the form. This identifier is essential for billing and connecting with federal systems.
Governing Law	State-specific regulations may apply. For example, in California, the form is governed under the California Dental Practice Act.

Guidelines on Utilizing Ada Dental Claim

Completing the ADA Dental Claim Form is a straightforward process. It's essential to ensure all relevant information is filled out accurately to avoid delays in processing. Begin by gathering all necessary information, including details about the patient, policyholder, and services provided. Once you have everything ready, follow the steps below to fill out the form correctly.

In the header section, mark all applicable boxes for the type of transaction.
If applicable, enter the predetermination/preauthorization number.
Provide the policyholder/subscriber information: include the name, address, city, state, and zip code.
Fill in the insurance company/dental benefit plan information: company's name, address, city, state, and zip code.
Add the date of birth of the policyholder/subscriber (MM/DD/CCYY) and their gender.
Provide the policyholder/subscriber ID (SSN or ID#).
If there is other dental or medical coverage, indicate 'Yes' or 'No'. If 'Yes', complete items 5-11.
For other coverage, provide the name of the policyholder/subscriber from item 4.
Fill out the patient information: relationship to policyholder, student status, date of birth, gender, and ID/account number.
Complete the record of services provided by entering the procedure date, tooth numbers, procedure codes, description, and fees.
For missing teeth, mark the relevant teeth in the designated section.
Summarize the total fee and add any relevant remarks.
In the authorization section, confirm awareness of treatment and agree to the financial responsibilities.
Complete any sections for orthodontics, if applicable.
Lastly, have both the patient/guardian and subscriber sign and date the form.

After filling out the form, ensure that all information is correct and legible. Properly folding the form will help it fit in a standard envelope for submission to the dental benefit plan. Keep a copy for your records, and then mail it to the appropriate insurance company to initiate the processing of your claim.

What You Should Know About This Form

What is the ADA Dental Claim Form used for?

The ADA Dental Claim Form is a standardized document that dental providers use to request payment for services rendered. It serves as the primary means for submitting claims to insurance companies for reimbursement. By capturing key information regarding the patient, the dental services performed, and the insurance plan details, the form helps streamline the claims process.

What information is required on the ADA Dental Claim Form?

When completing the ADA Dental Claim Form, several crucial pieces of information must be included. This includes the policyholder's name, address, and insurance company details, as well as the patient's relationship to the policyholder. Details about the procedures performed, such as the dates of service and associated fees, must also be entered. If the patient has other dental or medical coverage, that information should be completed as well. It is essential to provide all requested details to avoid delays or denials in processing.

How do I submit the ADA Dental Claim Form?

To submit the ADA Dental Claim Form, start by ensuring all relevant sections are fully completed. After verification, fold the form at the indicated tick-marks to ensure that the payer’s name and address are visible in a standard number 10 envelope. Then, send the form directly to the insurance company or dental benefit plan according to their specific submission guidelines. For secondary claims, attach the primary payer’s Explanation of Benefits (EOB) to ensure accurate processing.

What should I do if the claim is denied?

If the claim submitted on the ADA Dental Claim Form is denied, carefully review the explanation provided by the insurance company. Check if there are missing details or if any section needs clarification. It may help to contact the insurance company directly for a detailed explanation. Depending on the reason for denial, you may be able to correct the submission and resubmit the claim or appeal the decision. Always keep thorough records of your communications and submissions to help in the appeals process.

Common mistakes

Completing the ADA Dental Claim form can be straightforward, but several common mistakes can lead to delays in processing. Avoiding these pitfalls is essential to ensure timely reimbursement for dental services.

One frequent mistake is failing to mark the correct transaction type in the header information section. Forgetting to check all applicable boxes can result in claims being processed incorrectly or being returned for additional information. Being meticulous with this step is crucial.

Another error occurs when individuals omit the Policyholder/Subscriber ID. This number is vital for the insurance company to connect the claim to the appropriate account. If this field is left blank, it can lead to unnecessary delays.

Inaccurate patient information is also a common issue. Details such as the patient's name, date of birth, and relationship to the policyholder must be precise. Incorrect information might cause the claim to be rejected or delayed. Ensure the patient is correctly identified and information is entered accurately.

Many overlook the requirement for additional coverage details. If there is another dental or medical plan involved, failing to complete related sections can complicate coordination of benefits. Provide all necessary information regarding other insurances to avoid issues with coverage.

Another mistake is using incorrect or outdated dates. All dates on the form, including treatment dates and birth dates, must follow the MM/DD/CCYY format. Inaccurate dates can result in claims being processed improperly.

Finally, individuals often neglect to sign the form properly. A missing or incorrect signature can halt processing entirely. It’s important to ensure that the patient's or guardian's signature is present, along with the date, to authorize the billing process.

By paying attention to these details, individuals can significantly reduce the chances of errors that might delay their dental claims. A careful review prior to submission can save time and headaches down the line.

Documents used along the form

The ADA Dental Claim form is a vital document used by dentists to submit claims to insurance providers. This form initiates the process of reimbursement for dental services rendered. However, several other forms and documents may accompany the submission of the ADA Dental Claim form to ensure a smooth claim process. Below are some commonly used forms that can be helpful when seeking insurance benefits in dental care.

Explanation of Benefits (EOB): This document outlines the services provided, the amount billed, and what the insurance company has paid. It is crucial when filing secondary claims.
Prior Authorization Form: Required for certain dental procedures, this form seeks approval from the insurance company before the treatment is rendered, confirming coverage eligibility.
Patient Referral Form: A form that indicates a patient has been referred to a specialist by their primary dentist. This document helps in the coordination of care and insurance payments.
Medical History Form: This form collects essential health information about the patient, ensuring that the dentist is aware of any medical conditions that may impact treatment.
Consent Form: A document where the patient provides consent for the proposed treatment. It protects the dentist legally while informing the patient about the procedures.
Treatment Plan: A detailed outline of the recommended dental procedures, costs, and timelines. This helps the patient understand what is being billed to insurance and what might be out-of-pocket.
Claim Appeal Form: Used when a claim is denied, this form initiates the appeal process, allowing the provider to contest the insurance company's decision.
Coordination of Benefits Form: When a patient has multiple insurance plans, this form outlines which plan is the primary payer to prevent overpayment.
Receipt of Payment Form: This document serves as proof of payment for completed services, often required for insurance reimbursement requests.
Inventory of Services Provided: A comprehensive list detailing all services rendered during a specific dental visit, aiding in the claim's accuracy and transparency.

In summary, understanding and utilizing these forms can greatly enhance the efficiency of the claims process related to dental services. Each document serves a specific purpose, helping to clarify the information for both the patient and the insurer, ultimately leading to a smoother reimbursement experience.

Similar forms

CMS-1500 Form: The CMS-1500 form is used for submitting health insurance claims by medical providers. Similar to the ADA Dental Claim form, it requires detailed patient information, provider details, insurance company data, and specific services rendered. For both forms, accurate completion is essential for successful claims processing.
UB-04 Form: The UB-04 form is employed by hospitals and other institutional providers to bill for professional services. Like the ADA form, it captures patient demographics, billing provider information, and a detailed description of services, ensuring each claim is thorough and compliant with payer requirements.
Medicare Claim Form: This form is utilized by healthcare providers to submit claims for services rendered to Medicare beneficiaries. Both forms share a focus on documenting patient demographics, provider identification, and specific services provided, which facilitate proper reimbursement from insurance entities.
Patient Referral Form: A patient referral form allows healthcare providers to document and communicate patient referral details. Similar to the ADA form, it maintains essential patient data and specific treatment information, which aids in a seamless transition of care among providers.
Authorization for Release of Information: This document is used to permit the sharing of a patient’s protected health information with different entities. Comparable to the ADA form, it confirms patient consent and outlines the specific information to be shared, ensuring compliance with privacy regulations and proper administration of claims.

Dos and Don'ts

When completing the ADA Dental Claim form, it is important to be careful and thorough. Here is a list of things to remember, highlighting both things you should and should not do:

Ensure all applicable transaction types are marked clearly in the header section.
Fill out every required field completely, especially the names and addresses, using full details.
Double-check that all dates include the four-digit year format.
Submit additional procedures on a separate form if needed.

Do not skip any sections that are noted as required; incomplete forms can cause delays.
Avoid using abbreviations for names and addresses; write them out fully.
Do not forget to indicate any secondary insurance information if applicable.

Misconceptions

Here are some common misconceptions about the ADA Dental Claim Form, along with clarifications for each:

Misconception 1: The ADA Dental Claim Form is only for dental procedures.

This form can also be used for predetermination requests and preauthorizations, as specified in the transaction type section.

Misconception 2: All sections of the form are optional.

Every item must be completed unless noted otherwise. Incomplete forms can lead to delays in processing the claim.

Misconception 3: You do not need to include dates of service.

Correct completion requires exact procedure dates. All dates must also include the four-digit year.

Misconception 4: The form cannot accommodate multiple claims.

If the number of procedures exceeds available lines, the remaining items must be documented on a separate claim form.

Misconception 5: Only the primary insurance information is needed.

If other insurance covers the patient, it is mandatory to provide relevant details. Coordination of benefits is crucial in these cases.

Misconception 6: A policyholder's Social Security Number must be provided.

A patient's identification can be their unique subscriber ID. Using SSN is not a requirement unless specified otherwise.

Misconception 7: The National Provider Identifier (NPI) is optional for all dentists.

This identifier is required for HIPAA-covered entities. Non-covered dentists may obtain an NPI at their discretion, but it is advisable.

Misconception 8: The ADA Dental Claim Form is only relevant for traditional insurance plans.

This form is utilized by various dental benefit plans, including those associated with government programs.

Misconception 9: You can sign the form after submitting it.

The signature of the patient or guardian must be present at the time of submission to validate the claim.

Misconception 10: There are no specific codes needed for specializations.

Entering the correct provider specialty code is essential for accurately identifying the type of treatment delivered.

Key takeaways

Important Takeaways for Filling Out the ADA Dental Claim Form:

Complete all required fields: Ensure all relevant sections, including policyholder information, patient details, and record of services, are filled in as directed.
Use clear and accurate information: Provide full names, addresses, and dates (with four-digit years) as specified. Missing details can result in claim delays.
For secondary claims, attach necessary documentation: When submitting to a secondary payer, include the primary payer's Explanation of Benefits (EOB) for quicker processing.
Authorization signatures are crucial: Both the patient/guardian and the subscriber must sign and date the form to authorize payment directly to the dentist or dental entity.
Follow coordination of benefits rules: If the patient has multiple insurances, indicate the payments received and submit additional forms as necessary to avoid complications.

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