The ADA Dental Claim Form is a critical document utilized by dentists to submit insurance claims for dental services provided to patients. It encompasses details such as types of transactions, policyholder/subscriber and insurance company information, patient details, and records of services provided. Filling out this form accurately is essential for the timely processing of dental insurance claims. For a detailed guide on completing the ADA Dental Claim Form, click the button below.
The ADA Dental Claim Form stands as a critical document in the realm of dental care and insurance, bridging the gap between dental professionals and insurance companies. It meticulously records a range of details needed for the processing of dental insurance claims, including information about the policyholder, patient, and the dental services provided. This form, structured to ensure clarity and ease of use, includes sections for the type of transaction, policyholder and patient information, insurance and other coverage details, as well as specific data on the dental treatment provided - from the procedures performed to the fees involved. Additionally, it covers ancillary information relevant to the claim, such as authorizations and specifics about the treating dentist and location of treatment. With spaces dedicated for remarks, authorization signatures, and treatment documentation, the ADA Dental Claim Form encapsulates the comprehensive nature of dental treatment reporting and insurance claim submission. It's designed not only to streamline the reimbursement process but also to standardize the submission of dental claims across the board, ensuring that all necessary information is collected succinctly and accurately to facilitate prompt and accurate processing by insurance companies.
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
Filling out an ADA Dental Claim Form is essential for dental insurance claims or preauthorization requests. This document requires detailed information to ensure accurate processing and reimbursement. The following steps are designed to guide individuals through the completion process smoothly and effectively.
Once the ADA Dental Claim Form is completed, review it carefully to ensure all information is accurate and complete. Following the submission instructions provided by the dental insurance plan is crucial. This may include mailing the form to a specific address or submitting it online. After the form is submitted, the insurance company will process the claim, which may involve requesting additional information. It is advisable to keep a copy of the completed form and any correspondence with the insurance company for personal records and future reference.
What is the purpose of the ADA Dental Claim Form?
The ADA Dental Claim Form serves a critical function in the dental care sector by enabling patients or dental service providers to submit a claim to an insurance company or dental benefit plan for the cost of dental services rendered. This document helps to ensure that the financial transaction between dental care providers and insurance companies is smooth and efficient, facilitating reimbursements for services according to the terms of the patient's dental insurance coverage.
How do I know if I need to fill out an ADA Dental Claim Form?
If you have received dental services and wish to have these expenses covered by your dental insurance, your dentist's office may complete and submit an ADA Dental Claim Form on your behalf. In some cases, if the dentist does not directly coordinate with insurance plans, you may need to submit your dental claim using this form to seek reimbursement. Always verify with your dentist's office and your insurance company to understand their specific procedures for claim submissions.
What information is required on the ADA Dental Claim Form?
The form necessitates detailed information to be filled out, covering several aspects including type of transaction, policyholder and patient details, information on the dental service provider, a record of services provided, information about any other coverage, and authorization signatures from the patient or guardian. Specifically, it demands personal details (such as names and addresses), policy details (like policy numbers and insurance company information), as well as detailed descriptions of the dental services provided, including procedure dates, descriptions, and fees.
Can I fill out the ADA Dental Claim Form myself, or does my dentist need to do it?
Typically, your dental service provider or their administrative staff completes the ADA Dental Claim Form because it requires detailed technical information about the dental services provided, including specific dental codes for procedures and treatments. However, the policyholder or patient may need to provide personal and insurance-related information and sign the form, authorizing the submission of the claim. It's best to collaborate with your dental office to ensure the form is filled out correctly.
Is it mandatory to provide Social Security Numbers on the ADA Dental Claim Form?
While the form has fields for Social Security Numbers (SSNs) or ID numbers for both the policyholder and the patient, it's crucial to check with your specific dental insurance company regarding their requirements. Some insurance plans may allow alternative identifiers, especially given rising concerns about identity theft and privacy. Confirm with your insurer and dental office what information is necessary for your claim.
What should I do if my dental claim involves coordination of benefits?
If you are covered by more than one dental plan (referred to as coordination of benefits or COB), you need to fill out the ADA Dental Claim Form with information about both insurance plans. Additionally, when submitting your claim to the secondary insurance provider, attach the Explanation of Benefits (EOB) you received from the primary insurer that indicates the amount they have paid. This will help the secondary insurer determine their payment responsibility under the coordination of benefits policy.
Where can I find more information on completing the ADA Dental Claim Form?
More detailed instructions and guidance on completing the ADA Dental Claim Form can be found in Section 4 of the ADA publication titled CDT-2007/2008, as well as on the American Dental Association's website. These resources provide comprehensive instructions, making the process clearer for patients and dental service providers alike. Remember that understanding and correctly completing this form can expedite the claim process and ensure that benefits are utilized effectively.
Filling out the ADA Dental Claim form might seem straightforward, but there are common pitfalls that can trip anyone up. Here are nine mistakes people often make, causing unnecessary delays in processing or even denial of claims.
Firstly, it's crucial to ensure all information is accurate and complete, especially in the "Policyholder/Subscriber Information" and "Patient Information" sections. Missing or incorrect details about the policyholder or patient, such as the policy number or date of birth, can derail the entire process.
Ignoring the Type of Transaction box is another slip-up. Whether it's a statement of actual services provided or a request for predetermination/preauthorization, checking the correct box sets the right expectations for both the dental office and the insurance company.
Many people fail to attach a predetermination/preauthorization number when required. If the box indicating the need for predetermination/preauthorization is checked, failing to include this number can pause the claim processing, awaiting clarification.
Overlooking the details about other coverage can complicate the situation further. If there is other dental or medical coverage, it’s essential to provide information about the secondary policy. Concurrently, not attaching the primary payer's Explanation of Benefits (EOB), when the claim is for the secondary payer, also leads to unnecessary delays.
When it comes to the "Record of Services Provided" section, a common mistake is not accurately listing the procedures. Every detail, from procedure codes to tooth numbers or surfaces, needs to be meticulously recorded. Otherwise, claims can’t be processed accordingly.
Failing to report missing teeth information is yet another oversight. This might seem minor, but it's information that insurance companies consider essential for processing claims, especially in the case of replacements or related procedures.
A critical administrative step often missed is not signing the authorizations at the end of the form. Both the patient/guardian and the subscriber need to sign to authorize payment of benefits directly to the dentist and consent to the use of their health information.
Lastly, a frequent oversight is not including the National Provider Identifier (NPI) of the treating dentist. As an essential piece of information for claim processing in accordance with HIPAA regulations, omitting the NPI can prevent timely reimbursement.
Underestimating the importance of provider specialty codes, such as those for a general practice or a specific specialty like orthodontics, can also mislead insurance providers regarding the nature of treatment, affecting claim acceptance.
Avoiding these common mistakes can smooth the path of dental claims through the insurance system, ensuring prompt and accurate processing. It's all about attention to detail and providing clear, complete information every step of the way.
When dealing with dental claims, the ADA Dental Claim Form is critical for the reimbursement process for dental services. However, several other documents and forms often accompany this form to ensure a comprehensive submission package. These additional documents provide important details related to the patient's treatment, billing information, and insurance coverage, adding clarity and support to the claim.
Together, these forms and documents complement the ADA Dental Claim Form, creating a robust package that details every aspect of the patient's care, claim legitimacy, and the necessity for coverage. Dental professionals and patients must ensure these accompanying documents are accurate and complete to facilitate a smooth reimbursement process with the insurance carriers involved.
The Health Insurance Claim Form, often known as the CMS-1500, shares significant commonalities with the ADA Dental Claim Form. Both are standardized forms used in the healthcare industry to submit claims for services provided to patients; however, while the ADA form focuses on dental services, the CMS-1500 is used principally for medical claims. Each form gathers detailed information about the patient, the provider, the services rendered, and the charges, crucial for processing and reimbursement by insurance companies.
Another similar document is the UB-04 form, also known as the CMS-1450. It is utilized by hospitals and other inpatient facilities to claim insurance reimbursements. Like the ADA Dental Claim Form, it collects detailed information about the patient's treatment, including service dates, diagnosis codes, and charges. The main difference lies in their application settings, with the UB-04 being more aligned with inpatient and facility-based care billing.
The American Medical Association’s Current Procedural Terminology (CPT) codes are often included in documentation accompanying the ADA Dental Claim Form. CPT codes describe medical, surgical, and diagnostic services and play a critical role in the medical billing process, similar to dental procedure codes in dental claims. Both are essential for accurately describing the services provided to a patient and ensuring the proper processing of claims.
International Classification of Diseases (ICD) codes are used alongside the ADA Dental Claim Form in some cases, especially when specifying the diagnosis that necessitates dental services. ICD codes, like dental procedure codes, provide a standardized language for reporting and monitoring diseases and are vital for billing and record-keeping. Both types of codes ensure that healthcare providers can effectively communicate patient needs and services to insurers.
The Explanation of Benefits (EOB) document is closely related to the ADA Dental Claim Form as it is what patients receive from their insurance company after a claim has been processed. The EOB outlines what treatments were covered, the coverage amounts, and any patient responsibility. It directly corresponds to the claim form submitted and provides a clear breakdown of the financial transactions involved in the patient's care.
The Prior Authorization Form is another document similar to the ADA Dental Claim Form. It is used to request pre-approval from an insurance carrier before certain procedures or services are rendered, ensuring that they are covered under the patient’s plan. While the ADA form is used for billing after services are provided, both forms require detailed information about the proposed services and highlight the insurance industry's role in managing care.
The Patient Registration Form, typically filled out during a patient’s first visit to a healthcare provider, bears similarities to the ADA Dental Claim Form in that it collects personal and insurance information necessary for billing and insurance purposes. Although the Registration Form is used internally and focuses more on gathering comprehensive patient information, both documents are foundational to the administrative side of patient care.
Lastly, the Notice of Privacy Practices is a document that, while not a billing form, is connected to the ADA Dental Claim Form through its concern with patient information. It informs patients about how their health information may be used and shared, underlining the confidentiality aspect that is also inherent in the submission of any claim form. Both documents emphasize the importance of handling patient information with care and compliance with regulations.
Filling out the ADA Dental Claim Form can seem daunting, but it's vital for ensuring that dental services are accurately billed to insurance providers. Here are some dos and don’ts to help navigate through the process smoothly.
Understanding the complexities of the ADA Dental Claim Form can sometimes lead to misconceptions. Here are eight common misconceptions and the truths behind them:
Reality: This form is specifically designed for dental professionals to submit dental claims to insurance companies. It's not suitable for other types of medical claims.
Reality: Completing all sections with accurate personal information is essential to ensure the insurance company can process the claim efficiently. Inaccurate or incomplete information can lead to delays or denials.
Reality: The form is versatile and can also be used for requesting predeterminations or preauthorizations for dental services, not just for submitting claims for completed treatments.
Reality: When applicable, information about secondary insurance coverage should indeed be included. This helps facilitate coordination of benefits and ensures the patient receives the maximum benefit entitlement.
Reality: Each visit may require different services or treatments, so it's important to submit a new form for every claim, ensuring the most recent and relevant information is included.
Reality: The NPI is a mandatory field for all HIPAA-covered entities. This unique identifier must be included on the form for processing.
Reality: The "Remarks" section is intended for any additional information pertinent to the claim that the healthcare provider needs to communicate to the insurance company, not the patient's personal comments.
Reality: Whether a digital signature is acceptable depends on the insurance company’s policies. Always verify with the specific insurer's requirements before submitting a claim with a digital signature.
Understanding these key aspects of the ADA Dental Claim Form can help in ensuring accurate and efficient processing of dental claims, ultimately benefiting both the provider and the patient.
Filling out the ADA Dental Claim Form accurately is crucial for ensuring the timely processing of dental insurance claims. Here are key takeaways to keep in mind:
Remember to review all sections of the ADA Dental Claim Form for completeness and accuracy before submitting it to the insurance company. This helps in avoiding delays and ensures the patient or policyholder receives their entitled benefits promptly.
Mod 21 Rfi Editável - Significantly reduces bureaucratic hurdles for non-residents by elucidating the process for claiming tax exemptions on income earned in Portugal.
Form 17 Real Estate - Ensures sellers disclose any known zoning violations, boundary disputes, and encroachments that could affect the buyer's use of the property.
Virginia Beach Clerk Office - It balances the need for detailed recording with the efficiency of a standardized format, making it a critical tool in property law and administration.