The ADA Dental Claim Form is a critical document used within the dental and insurance industries to file claims for dental services rendered. By providing essential details such as policyholder information, insurance company details, patient and treatment data, and records of services provided, it ensures the accurate and timely processing of dental claims. The form is designed to be comprehensive, accommodating various types of transactions including actual services rendered and requests for preauthorization or predetermination of services.
Filling out the American Dental Association (ADA) Dental Claim Form can seem like a daunting task with its comprehensive sections and detailed fields, but it serves as a crucial bridge between dental services provided, and the insurance companies that help manage the cost of such services. At the heart of the form are sections that capture everything from the type of transaction, detailed policyholder and patient information, to records of the services provided, and even information regarding other coverages and ancillary claim or treatment information. The form carefully balances the need for exhaustive data to accurately process dental claims with the practicality of being user-friendly. Instructions for folding the form for mailing, entering provider identification numbers, and documenting coordination of benefits underscore the ADA's attention to ensuring the form meets the needs of all stakeholders involved in the dental care and insurance billing process. This form also adapts to various scenarios, including considerations for orthodontic treatment, accidents, and work-related injuries. Its thoughtful design, highlighted by sections like the 'Remarks' field for unique circumstances and the provision for additional provider identifiers, reflects a comprehensive approach to managing dental claims, making it an indispensable tool in the dental care and insurance industry.
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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 an ADA Dental Claim form is crucial for ensuring that dental services are billed accurately to insurance providers, facilitating the reimbursement process for both patients and dental practices. The form may appear daunting at first glance, but breaking it down into manageable steps can simplify the process. Whether you're completing this form for the first time or just need a refresher, follow these steps to ensure it's done correctly.
Once the form is completely filled out, review all the information for accuracy. If submitting a claim for secondary coverage, attach the primary payer’s Explanation of Benefits (EOB). Remember, all dates must include the four-digit year, and it's vital to adhere to the instructions for each section as outlined on the ADA form. Properly completed forms ensure timely and accurate processing of dental claims, aiding both patients and dental practices in managing the financial aspects of dental care.
What is the purpose of the ADA Dental Claim Form?
The ADA Dental Claim Form is designed for dental professionals to submit claims to dental benefit plans for services provided to insured individuals. Its primary purpose is to facilitate the reimbursement of dental services covered under an insurance policy. The form supports different types of transactions, including statements of actual services rendered, requests for preauthorization or predetermination, and EPSDT/Title XIX services for Medicaid participants.
How should the ADA Dental Claim Form be completed and submitted to fit in a standard #10 window envelope?
To ensure the form fits properly in a #10 window envelope, it should be folded according to the 'tick-marks' printed in the margin. This arrangement ensures that the name and address of the third-party payer (insurance company or dental benefit plan) specified in Item 3 are visible through the envelope's window, facilitating the correct delivery of the claim form.
Is it necessary to fill out all sections of the ADA Dental Claim Form?
All sections of the ADA Dental Claim Form should be completed unless indicated otherwise on the form itself or in the accompanying instructions. The requirement for comprehensive completion is crucial for the accurate processing of the dental claim. Details such as the insurance company's name and address, policyholder's information, and detailed records of services provided are essential. In cases where the number of procedures exceeds the space provided, additional procedures must be listed on a separate claim form, which also needs to be fully completed.
What is the significance of the National Provider Identifier (NPI) on the ADA Dental Claim Form?
The National Provider Identifier (NPI) is a unique identification number for health care providers, including dentists, mandated by the federal government for all HIPAA-covered entities. On the ADA Dental Claim Form, the NPI facilitates the unique identification of the individual dentist (Type 1 NPI) or dental entity (Type 2 NPI) providing the treatment. This identifier is critical for streamlining the processing of dental insurance claims and enhancing the efficiency of electronic transmission of health information.
What should be done when submitting a claim to a secondary insurer?
When a dental claim is submitted to a secondary insurance company, the ADA Dental Claim Form must be completed in its entirety. Additionally, the primary payer’s Explanation of Benefits (EOB), which shows the amount paid by the primary insurance, must be attached. Information on the payment made by the primary insurer can also be indicated in the "Remarks" section (Item #35). This process ensures that the secondary insurer has all the necessary information to coordinate benefits appropriately.
How can updates to the ADA Dental Claim Form completion instructions be accessed?
Any updates to the completion instructions for the ADA Dental Claim Form are made available on the American Dental Association’s website. Dental professionals can visit www.ada.org/goto/dentalcode to find the most current information and instructions. This resource ensures that the dental claims are always prepared in accordance with the latest guidelines, facilitating their successful processing by dental benefit plans.
One common mistake individuals make when completing the ADA Dental Claim form is not providing complete header information. This includes omitting the type of transaction in the opening section. It is crucial to mark all applicable boxes, such as "Statement of Actual Services" or "Request for Predetermination/Preauthorization," to ensure the insurance company understands the purpose of the form submission.
Another error often encountered is in the section concerning policyholder/subscriber information. Individuals frequently fail to fully complete their name, address, and other contact details. Specifically, neglecting to include the middle initial or suffix when listed on the policy can lead to unnecessary delays in processing the claim. Accurate and full information ensures that the form is matched correctly to the insurance policy.
A third mistake is incorrectly filling out the insurance company or dental benefit plan information. Not providing the complete company/plan name, address, city, state, and zip code can significantly hinder the processing of the claim. This information is critical for the insurance company to identify the correct plan and benefits that apply.
A fourth area where errors are commonly made is in the section addressing other coverage. When individuals have additional dental or medical coverage, it is essential to complete details about the secondary policyholder/subscriber. However, many fail to do so, forgetting to fill out the needed information about the secondary insurance, if applicable. This oversight can complicate benefit coordination between the primary and secondary insurers.
Fifth, inaccuracies in the patient information section, especially regarding the relationship to the policyholder/subscriber and the student status, can also pose problems. It is vital to accurately describe the patient's status, as it can affect eligibility and coverage details. Misrepresentation or mistakes in this section can lead to denied claims.
Last but not least, mistakes in the record of services provided, such as omitting procedure dates, tooth numbers, or incorrect procedure codes, can result in rejected claims or incorrect benefit payments. It is important to provide a detailed account of the services rendered, using the correct dental nomenclature and codes, to facilitate accurate and timely processing of the claim.
When handling dental claims, it's crucial to have all necessary documentation ready to ensure a smooth and efficient processing experience. In addition to the ADA Dental Claim Form, several other forms and documents often play a pivotal role in this process. These materials help in providing a comprehensive view of the dental treatment, aiding in the determination of benefits and ensuring that all parties are adequately informed.
Effectively gathering and managing these forms and documents alongside the ADA Dental Claim Form can significantly impact the claims processing timeline and the overall patient experience. These materials not only support the claim but also serve as a communication tool among the dental office, patients, and insurance companies, fostering transparency and trust throughout the dental care journey.
The Health Insurance Claim Form (HCFA-1500) is similar to the ADA Dental Claim Form in that both are used by healthcare providers to claim payment from insurance companies. They collect detailed information about the policyholder, the patient, and the services provided, including procedure codes and fees.
The Universal Claim Form shares similarities with the ADA Dental Claim Form in its purpose of submitting insurance claims. It is designed for use across various types of healthcare providers, capturing patient and provider information, services rendered, and billing details.
Automobile Insurance Claim Form is another document that parallels the ADA Dental Claim Form. It is used to claim for expenses related to auto accidents, including medical treatment required due to the incident, detailing the claimant's insurance and treatment information.
The Workers' Compensation Claim Form is akin to the ADA Dental Claim Form as it is used to request insurance benefits. It specifically pertains to injuries suffered at work, gathering comprehensive information about the employee, the employer, and the medical services received as a result of the workplace injury.
Medicare Claim Form resembles the ADA Dental Claim Form in the aspect of claiming health insurance benefits, specifically from Medicare. It requires detailed patient information, details of the healthcare provider, and information on the services provided, focusing on individuals covered by Medicare.
The Vision Care Claim Form is comparable to the ADA Dental Claim Form since both are specialized insurance claim forms, one for dental and the other for vision care services. Both documents collect patient and provider information, details of the coverage, and descriptions of the services provided, including dates and fees.
Pharmacy Benefit Claim Form has similarities with the ADA Dental Claim Form as both are used within the healthcare sector to claim insurance benefits for services rendered. The pharmacy claim form specifically deals with prescription medications, including patient information, prescription details, and billing information.
Disability Insurance Claim Form is another document that is parallel in function to the ADA Dental Claim Form. It is utilized for claiming disability benefits, requiring detailed information on the claimant's medical condition, employment status, and the disability's impact on their work ability, along with provider information.
The Property Insurance Claim Form, while generally used for claiming damages or losses related to property, shares the commonality with the ADA Dental Claim Form of necessitating detailed information for insurance claims processing. This includes the claimant's personal details, information on the insurance policy, and specifics of the claim.
Life Insurance Claim Form is similarly purposed to the ADA Dental Claim Form in terms of claiming insurance benefits. Though focused on life insurance payouts due to death, it requires detailed information about the policyholder, the beneficiary, and the circumstances surrounding the claim.
When completing the ADA Dental Claim Form, it's important to follow certain guidelines to ensure the claim is processed efficiently and accurately. Below are things you should and shouldn't do while filling out the form:
Understanding the ADA Dental Claim Form can sometimes be as tricky as a root canal. There are a bunch of myths floating around that need to be cleared up. So, let's dive into the misconceptions and set the record straight.
Every section must be filled out: Not exactly. While the ADA Dental Claim Form has many sections, not all need to be completed for every claim. The guidance specifies sections that are optional based on the type of claim being submitted.
The form is only for adult patients: This is not true. The form is designed for patients of all ages, including children, as seen in sections like the EPSDT/Title XIX marker for those under public health insurance programs for minors.
It's only for primary insurance claims: Incorrect. The form can be used for both primary and secondary insurance claims. For secondary claims, it's important to attach the primary payer's Explanation of Benefits (EOB) and indicate the primary payment in the remarks section.
Only dentists can fill out the form: While dentists or their authorized representatives typically fill out the form, office staff are also permitted to do so under the dentist's supervision, as long as all information is accurate and complete.
NPI is optional: Not quite. The National Provider Identifier (NPI) is a must-have for any dentist who is a HIPAA covered entity. This unique identifier is crucial for processing the claim.
The ADA Dental Claim Form is outdated: False. The ADA updates the claim form and its completion instructions regularly to reflect changes in dental practice and insurance requirements. Always check for the latest version.
Any tooth notation system will do: The form requires using the specific Universal/National tooth numbering system and the ISO System for the "Tooth System" field, ensuring clarity and standardization in identifying teeth.
Secondary insurance details go in the remarks section: While it's true that some information about secondary insurance can be noted in the remarks, the form has dedicated sections for detailing other dental or medical coverage, ensuring comprehensive insurance information is provided.
Manual submission is the only way: This used to be the case, but many insurance companies now accept electronic submissions of the ADA Dental Claim Form, making the process faster and more efficient.
Dispelling these myths can save time and prevent headaches for patients, dental practitioners, and office staff alike. Always refer to the current ADA guidelines and instructions for completing the dental claim form effectively.
When properly completing the ADA Dental Claim Form, it's essential to understand the following key takeaways to ensure accuracy and timeliness in processing dental insurance claims:
Following these guidelines when filling out the ADA Dental Claim Form will help facilitate the processing of dental claims. It ensures that patients' claims are handled efficiently, accurately, and in compliance with insurance protocols.
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