The ADA Dental Claim Form serves as a critical tool for documenting and submitting dental treatment information to insurance companies. It is structured to outline details of the treatment, the patient, and policyholder information, necessary for the insurance process. For those needing to manage dental claims effectively, understanding how to meticulously fill out each section of this form is essential.
Ready to navigate your dental claims with ease? Click the button below to learn the step-by-step process of filling out the ADA Dental Claim Form.
Navigating the intricacies of dental health care claims can be a labyrinthine process, fraught with specific details and requirements that both providers and patients must adhere to for successful reimbursement and coverage. At the heart of this process lies the ADA Dental Claim Form, a critical document designed to streamline the submission of dental claims to insurance companies. This form collects comprehensive information about the type of transaction – be it a statement of actual services, a request for predetermination/preauthorization, or other specified services – along with detailed policyholder, subscriber, and patient information. It demands precise data, including the policyholder's and patient's names, addresses, date of birth, gender, and pertinent insurance details such as policy numbers and company information. Additional sections delve into the patient's coverage under other plans, the relationship to the policyholder, and their student status, ensuring a thorough context for the insurer. The form further enumerates the services provided, including procedure dates, tooth numbers, procedure codes, associated fees, and any missing teeth information, culminating in a total fee calculation. Authorizations, treatment place, and any ancillary claim or treatment information are also requisite, alongside declarations regarding orthodontic treatment, accident-related inquiries, and the treating dentist’s certification. Designed with both functionality and confidentiality in mind, this form ensures that all necessary data for claim processing is captured succinctly, while also accommodating the privacy and information security mandates of healthcare legislation. With the aim of simplifying claims processing for both dental providers and insurance companies, the ADA Dental Claim Form stands as a cornerstone of efficient dental care administration.
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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#)
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
Filling out the ADA Dental Claim form requires attention to detail and accuracy to ensure that claims are processed smoothly and efficiently by the insurance company. This task involves providing comprehensive information about the policyholder, patient, dental treatment received, and billing details. The form serves as a critical communication tool between dental care providers and insurance companies, facilitating the adjudication of claims for dental services rendered. By following the steps listed below, one can navigate through the form, providing all the necessary details that pave the way for a successful claim submission.
Once the ADA Dental Claim form is fully completed with the requisite information, it should be either mailed to the insurance company or submitted according to the specific instructions provided by the insurer. Ensuring that all sections are accurately filled will streamline the claims processing, leading to a timely reimbursement for dental services rendered.
The American Dental Association (ADA) Dental Claim Form is a document that dental care providers use to claim reimbursement from dental insurance companies. It's designed to detail the services provided to a patient, including treatment dates, procedure codes, tooth numbers and surfaces, and the fees charged for each service. This form can be used not only for claiming payment for actual services rendered but also for requesting predetermination/preauthorization of services, which is when a provider seeks confirmation from an insurance company that a treatment is covered under a patient’s dental plan. Moreover, it includes sections for reporting other insurance coverage, patient and policyholder information, and detailed treatment information.
To accurately fill out the policyholder/subscriber information on the ADA Dental Claim Form, you will need to provide the name, address, city, state, and ZIP code of the policyholder or subscriber. Specifically, this is referring to the individual who holds the insurance policy under which the dental services were provided. You'll also need to input the policyholder's date of birth, gender, and their policy or subscriber ID, which might be a Social Security Number (SSN) or another form of identification number. This section ensures that the dental insurance company can correctly identify the policyholder and apply the benefits accordingly.
If the patient has other dental or medical coverage, it's essential to complete sections 4 through 11 on the ADA Dental Claim Form. This includes providing information about the additional policyholder or subscriber, such as their name, date of birth, gender, policy or subscriber ID, and employer name. You should also specify the patient's relationship to this additional policyholder, and details about the other insurance company, like its name and address. This information helps in the coordination of benefits, ensuring that all applicable insurance policies are billed properly and that the patient receives the maximum benefits available.
The National Provider Identifier (NPI) plays a critical role on the ADA Dental Claim Form. It is a unique identification number for covered health care providers in the United States. For dentists, the NPI must be included in items 49 and 54 of the form. This identifier helps streamline the processing of dental claims and ensures accurate and speedy reimbursement by enabling insurance companies to easily verify the identity and credentials of the dental care provider. Dentists and dental entities recognized as HIPAA covered entities are required to obtain and use an NPI. Opting to include the NPI on claims forms, even when not mandated, can facilitate better coordination with insurance companies and other health care providers.
Filling out an ADA Dental Claim Form accurately is crucial to ensure timely processing and payment of claims. However, common mistakes can delay this process. Here are eight errors often made:
Not marking the correct type of transaction at the top of the form. There are different boxes to check based on whether the claim is for actual services provided, a request for predetermination/preauthorization, or an EPSDT/Title XIX (Early and Periodic Screening, Diagnostic, and Treatment/ Medicaid) claim.
Failing to provide the predetermination/preauthorization number when required. If the services need preauthorization, this number is crucial for processing the claim.
Incorrectly filling out the policyholder/subscriber information section. This includes the policyholder's name, address, and other key details. Errors here can misdirect the claim or cause delays.
Omitting or incorrectly entering the policyholder/subscriber ID. This is typically a Social Security Number or an ID number provided by the insurance company and is essential for identifying the policy under which the claim is filed.
Overlooking other coverage details. If there's another dental or medical coverage, all details including the name of the policyholder of the other policy must be provided. Leaving this section blank or incomplete can complicate the coordination of benefits.
Providing incomplete patient information. Each field from the patient's relationship to the policyholder, through to their student status, needs careful attention to ensure the claim relates to the correct individual and their eligibility for coverage.
Not listing all services provided due to space constraints. If the provided space isn't enough, the correct process is to use a second form for the additional procedures, ensuring all provided services are accounted for.
Forgetting to sign and date the authorization section. The signatures of the patient or guardian and the subscriber are mandatory for the claim to be processed. Without these, the form is considered incomplete.
By avoiding these common mistakes, the processing of ADA Dental Claims can be smoother and faster, benefiting both the provider and the patient.
When processing dental claims, the ADA Dental Claim Form is just one piece of the puzzle. There are several other forms and documents that frequently accompany it to ensure a smooth and efficient handling process. Understanding these additional documents can greatly assist in preparing for claim submissions or queries from insurance companies.
In addition to these forms, always stay updated with changes in insurance policies and claim filing requirements. Proper documentation supports the billing process, ensuring that both the patient and the dental practice have a clear understanding of the treatments and financial responsibilities involved.
The Health Insurance Claim Form, commonly identified with CMS-1500 for medical claims, closely aligns with the ADA Dental Claim Form. Both serve as standardized paperwork for healthcare providers to communicate with insurance companies or payers. They collect essential patient information, the provider's identification, and detailed service descriptions to process claims efficiently. Each section of the forms is dedicated to capturing specific elements such as patient demographics, insurance details, and service codes, ensuring that claims are comprehensively documented and accurately processed.
The Automobile Insurance Claim Form is another document akin to the ADA Dental Claim Form by its function in insurance claims processing. Specifically, when dental injuries are the result of an automobile accident, the ADA form may parallel the auto insurance claim process. Both documents gather information on the incident, insurance coverage details, and specific injury or treatment information. They are crucial in determining liability and benefits coverage for the insured, ensuring parties injured in auto accidents receive proper compensation for medical or dental services received.
Workers' Compensation Claim Forms share similarities with the ADA Dental Claim Form, particularly when dental services are required due to a workplace injury. These forms both play pivotal roles in the insurance claims process, documenting detailed information about the patient, the nature of the injury or illness, treatment details, and provider information. The purpose is to establish the connection between the workplace incident and the necessary medical or dental treatment, facilitating the adjudication process and ensuring that injured workers receive the benefits to which they are entitled.
Disability Insurance Claim Forms, while primarily associated with income replacement, often require detailed medical or dental information similar to what is captured in the ADA Dental Claim Form. When dental conditions or surgeries impact an individual's ability to work, both types of forms become integral in documenting the condition, its impact on the patient's employment capabilities, and the expected duration of the disability. They ensure that individuals receive the appropriate support and financial benefits during their recovery period.
Filling out the ADA Dental Claim form correctly is essential for ensuring timely and accurate processing of dental insurance claims. Here are some important do's and don'ts to consider:
Remember, any errors or omissions on the form can lead to delays in the processing of claims, which can affect the timely payment to dental providers and potentially lead to out-of-pocket expenses for patients. It's in everyone's best interest to ensure the form is filled out correctly and completely the first time.
Misunderstandings about the ADA Dental Claim Form can create unnecessary confusion and delays in the processing of dental claims. Here are nine common misconceptions explained:
Understanding these points about the ADA Dental Claim Form can facilitate a smoother, more efficient claims process, ensuring that you or your dental practice can secure the appropriate coverage and compensation for dental services rendered.
Filling out and using the ADA Dental Claim Form accurately is essential for the timely and accurate processing of dental insurance claims. Here are key takeaways to help navigate this process:
Accurate and comprehensive completion of the ADA Dental Claim Form helps facilitate quick processing and reimbursement for dental services rendered. Always refer to the most current form and instructions to ensure compliance with any updates or changes.
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