The Ada Dental Claim Form is a crucial document used for submitting dental claims to insurance companies. It captures essential information about the patient, the insurance policy, and the services provided. Understanding how to fill out this form properly can streamline the claims process significantly, ensuring prompt reimbursement for dental services rendered. Fill out the form by clicking the button below.
The ADA Dental Claim Form is a critical document used in the dental industry to facilitate the processing of insurance claims, ensuring that patients receive the coverage they are entitled to for dental care. This form requires essential header information, such as the type of transaction being requested—whether it's a statement of actual services, pre-determination, or pre-authorization. Policymaker and subscriber details must be meticulously filled, including names, addresses, and policy numbers. Equally important is the patient information section, which further specifies the relationship to the policyholder, along with necessary identifiers like date of birth and insurance coverage details. The record of services provided is a crucial area where dental professionals list each procedure performed, including dates, descriptions, and associated fees. Additional sections deal with authorizations, treatment details, and the required signatures of patients or guardians, confirming their understanding and consent regarding the treatment plans and financial responsibilities. Adhering to these instructions and ensuring all information is complete is vital for a successful claim submission, making the ADA Dental Claim Form an essential tool for both providers and patients in navigating dental care payments.
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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 accurately is essential for ensuring that your claim is processed efficiently. By following the steps below, you will be able to provide all the necessary information required for the claim review and approval.
Make sure to double-check each section for accuracy before submitting the claim to your dental insurance provider. Each piece of information is vital to the processing of your dental claim, and diligence in this step can help avoid delays.
What is the purpose of the ADA Dental Claim Form?
The ADA Dental Claim Form is used to submit claims for dental services provided to patients. This form is typically completed by dental practitioners and sent to insurance companies to seek reimbursement for various dental treatments. It helps streamline the claims process and ensures that all necessary information is provided to the insurance payer.
What information do I need to provide on the form?
The form requires a variety of information, including:
It's important to fill in all required fields to avoid delays in processing your claim.
What should I do if I have other dental insurance?
If you have other dental coverage, you need to provide that information on the claim form. Specifically, you'll need to fill out sections regarding the other policyholder and plan details. The form is structured to accommodate claims that involve coordination of benefits, so be sure to include this information accurately.
How do I know if I completed the form correctly?
Carefully reviewing the ADA Dental Claim Form is crucial. Ensure that:
Consult the completion instructions provided by the ADA if you have questions about specific fields or required information.
What is an NPI, and why is it needed?
The National Provider Identifier (NPI) is a unique identification number for healthcare providers, including dentists. It is necessary for billing purposes and helps ensure that claims are processed correctly. You must include your NPI on the form if you are a covered entity under HIPAA.
What happens if I forget to attach the Explanation of Benefits (EOB)?
If you are submitting a claim to a secondary insurance provider, it is vital to attach the EOB from the primary payer. Failing to do so could result in delays or denials of your claim, as the secondary payer needs this information to process your claim accurately.
How do I submit the completed claim form?
The completed ADA Dental Claim Form can be submitted via mail or electronically, depending on your dentist's office and your insurance company’s requirements. If mailing, ensure you fold the form properly so that the address of the insurance company is visible through a standard window envelope.
How long will it take to process my claim?
Processing times can vary depending on the insurance company. Generally, you can expect a wait of several weeks, but some claims may be processed faster than others. If you have not received a decision after a reasonable amount of time, consider following up with your insurance provider for an update.
What should I do if my claim is denied?
If your claim is denied, review the reason provided by your insurance company. You can often appeal the decision by submitting additional information or correcting any errors on the submission. Refer to your insurance policy for detailed guidance on the appeals process.
Filling out the ADA Dental Claim Form can seem like a straightforward task, but many people make errors that can delay processing and payments. One common mistake is leaving out essential personal information. This includes important details about the policyholder or subscriber, such as their full name and complete address. If these areas are incomplete, the claim may not reach the intended insurance company.
Another frequent error involves the selection of transaction types. Individuals often neglect to mark all applicable boxes for transactions like "Statement of Actual Services" or "Request for Predetermination/Preauthorization". Failing to do this can lead to confusion and potentially result in the rejection of the claim. Each box serves a purpose; thus, ensuring all relevant options are checked is crucial.
Moreover, people sometimes forget to provide detailed descriptions of the services rendered. It is not enough to only list procedure codes; explanations for the work done are necessary. Without a clear and detailed description, insurance companies may have difficulty understanding the procedures, which could delay reimbursement.
Another mistake often made is regarding the dates. Individuals might enter dates in an incorrect format or fail to include the four-digit year. Dates play a significant role in claims processing, as discrepancies can raise questions about the validity of the services claimed. Always double-check to ensure the dates are presented correctly.
Some claimants also fail to address coordination of benefits when applicable. If there’s secondary insurance, it’s crucial to provide all the required information. Not attaching the primary payer’s Explanation of Benefits (EOB) could result in the secondary claim being denied. Clarity and completeness in this section ensure that all potential benefits are maximized.
Lastly, individuals may overlook the signature requirement. The form requires a signature from both the patient or guardian and the treating dentist. Failure to obtain these signatures can lead to automatic denials. Ensuring that all signatures are in place before submission will speed up the process and help avoid unnecessary setbacks.
The ADA Dental Claim Form is a crucial document for individuals seeking reimbursement for dental services. Often used alongside this form are other vital documents that allow for effective communication between the provider, the patient, and the insurance company. Below is a description of nine common forms and documents that are frequently used in conjunction with the ADA Dental Claim Form.
Each of these documents plays a significant role in the process of claiming dental expenses. They ensure that all necessary information is communicated effectively, helping to alleviate delays and misunderstandings that can often arise in the reimbursement process. Having these documents organized and readily available can facilitate smoother interactions with insurance companies and enhance the overall experience for the patient.
CMS-1500 Form: This form is widely used for billing medical services and is similar in structure to the ADA Dental Claim Form. Both forms require patient demographic information, provider details, and service descriptions, making them essential for insurance claims.
UB-04 Form: Typically used by hospitals for billing institutional services, the UB-04 shares similarities in that it includes patient and provider information, as well as treatment records. Both forms aim to streamline payment processes from insurance providers.
Medicare Claim Form (CMS-1490S): This form is designed for patients to submit claims directly to Medicare. Similar to the ADA form, it features detailed sections regarding service dates, billing information, and identification numbers.
Health Insurance Claim Form (HICF-1500): This is a variation specifically used by some health insurers. Like the ADA Dental Claim Form, it includes sections for patient information, insurance details, and specific services rendered.
Blue Cross Blue Shield (BCBS) Claim Form: This form is used within the Blue Cross Blue Shield network for dental or medical claims. It mirrors the ADA form by requiring information about the insured, the provider, and the services provided.
State-Specific Dental Claim Forms: Many states have their own dental claim forms that include information on treatment and patient identification. These share structural similarities with the ADA form, focusing on pertinent patient and service data.
Veterans Affairs Claim Form (VA Form 10-7959a): This form is utilized by veterans for dental service claims. It resembles the ADA form in the way it captures patient demographics, provider information, and specifics about the dental services performed.
Workers’ Compensation Claim Form: Used for claims related to work-related injuries, this form demands specific details about the incident and treatment. It has a similar layout to the ADA form, necessitating patient and procedure details to facilitate claims processing.
When filling out the ADA Dental Claim Form, it is essential to adhere to certain guidelines to ensure proper processing. Here is a list detailing actions to take and actions to avoid:
Understanding the ADA Dental Claim Form can be tricky, and misconceptions often prevent people from effectively using it. Here is a list of common misunderstandings about this important document, along with explanations to clarify them.
A better understanding of these misconceptions can help streamline your claims process, facilitating a more effective experience with your dental insurance.
Ensure you fill in the header information completely. This includes indicating the type of transaction and providing the necessary policyholder details.
If there is other dental or medical coverage, complete all required sections. Failing to do so can lead to delays in processing your claim.
Accurately provide the patient information. This includes the relationship to the policyholder and their gender and date of birth.
Document each service procedure provided. This means including the date, tooth number, and fee associated with the services rendered.
Use the remarks section wisely. If there’s a secondary payer involved, include details regarding payments made by the primary payer.
Complete the form in its entirety. Each section must be filled out since incomplete forms can lead to rejection from the insurance company.
Double-check all identifiers, including the NPI and any additional provider identifiers. These numbers are crucial for processing the claim accurately.
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