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Download Ada Dental Claim Template

The Ada Dental Claim Form is a standardized document used to submit dental claims to insurance companies and dental benefit plans. This form captures essential information about the patient, the policyholder, and the services provided, ensuring that claims are processed efficiently. Understanding how to complete this form accurately is crucial for both dental providers and patients to facilitate timely reimbursement and avoid potential delays.

Open Ada Dental Claim Editor

Open Ada Dental Claim Editor

Content Overview

The ADA Dental Claim Form serves as a crucial document in the dental billing process, ensuring that dental services are accurately reported and reimbursed by insurance providers. This form includes essential header information, such as the type of transaction being submitted, which can range from a statement of actual services to requests for predetermination or preauthorization. It requires detailed policyholder and subscriber information, including names, addresses, and identification numbers, to facilitate proper claim processing. Additionally, the form captures patient information, including their relationship to the policyholder and any other insurance coverage that may apply. A comprehensive record of services provided is also included, detailing procedure dates, tooth numbers, and associated fees. Furthermore, the form incorporates sections for authorizations and ancillary claim information, allowing for the submission of multiple procedures and the coordination of benefits when applicable. Each section must be completed thoroughly to avoid delays in payment, and specific instructions guide users in ensuring that all necessary details are accurately reported. Overall, the ADA Dental Claim Form is designed to streamline the claims process, making it easier for dental professionals to receive timely reimbursement for their services.

Key takeaways

When filling out the ADA Dental Claim Form, there are several important points to keep in mind. These takeaways will help ensure that your submission is complete and accurate.

Complete All Sections: Fill out every section of the form, unless specified otherwise. Missing information can delay processing.
Use Clear and Accurate Information: Provide full names, addresses, and dates. Avoid abbreviations to prevent confusion.
Mark Applicable Transactions: Indicate all types of transactions that apply to your claim, such as requests for predetermination or actual services.
Check for Other Coverage: If the patient has other dental or medical coverage, complete the relevant sections to ensure coordination of benefits.
Attach Necessary Documents: If submitting to a secondary payer, include the primary payer’s Explanation of Benefits (EOB) with your claim.
Sign and Date: Ensure that both the patient or guardian and the treating dentist sign and date the form where required.
Use the Correct Provider Identifiers: Include the National Provider Identifier (NPI) and any additional provider ID numbers as necessary.
Keep Copies: Always keep a copy of the completed claim form and any attachments for your records.
Follow Up: After submitting the claim, follow up with the insurance company to confirm receipt and inquire about the status.

By adhering to these key takeaways, you can help ensure a smoother claims process and reduce the likelihood of delays or denials.

Guide to Writing Ada Dental Claim

Completing the ADA Dental Claim Form is a straightforward process, but it requires attention to detail to ensure accuracy. Following the steps outlined below will help you fill out the form correctly, facilitating the claim submission to your dental insurance provider.

Type of Transaction: Mark all applicable boxes at the top of the form, indicating whether you are submitting a Statement of Actual Services, a Request for Predetermination/Preauthorization, or if it relates to EPSDT/Title XIX.
Predetermination/Preauthorization Number: If applicable, enter the number provided for this purpose.
Policyholder/Subscriber Information: Fill in the name (Last, First, Middle Initial, Suffix), address, city, state, and zip code of the policyholder or subscriber.
Insurance Company/Dental Benefit Plan Information: Provide the name of the insurance company or dental plan, along with its address, city, state, and zip code.
Date of Birth: Enter the policyholder/subscriber's date of birth in MM/DD/YYYY format.
Gender: Indicate the gender of the policyholder/subscriber by marking M or F.
Policyholder/Subscriber ID: Provide the Social Security Number or ID number of the policyholder/subscriber.
Other Coverage: If there is other dental or medical coverage, answer 'Yes' and complete the required fields (5-11). If 'No', skip to the next section.
Patient Information: Fill in the relationship of the patient to the policyholder/subscriber, the patient's date of birth, gender, and ID/account number assigned by the dentist.
Record of Services Provided: Enter details for each procedure, including the procedure date, area, tooth number(s), surface code, description, and fee.
Missing Teeth Information: Mark the appropriate boxes for missing teeth and enter the total fee for services.
Authorizations: Read and sign the authorization statement, agreeing to be responsible for any charges not covered by the dental benefit plan.
Treating Dentist Information: Provide the name, address, and contact details of the treating dentist or dental entity, including their NPI and license number.
Billing Dentist Information: If applicable, fill in the billing dentist's details, including their NPI and any additional provider identifiers.

After completing the form, review it carefully to ensure all necessary fields are filled out accurately. Once confirmed, submit the form to your insurance provider along with any required documentation, such as an Explanation of Benefits if you have secondary coverage. This will help facilitate the processing of your claim efficiently.

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Form Preview 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

fold

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

Documents used along the form

When navigating the world of dental insurance claims, understanding the various forms and documents that accompany the ADA Dental Claim Form is essential. These additional documents can streamline the claims process, ensuring that all necessary information is provided to insurance companies for timely processing. Below is a list of commonly used forms that may be required alongside the ADA Dental Claim Form.

Explanation of Benefits (EOB): This document is issued by the insurance company after a claim has been processed. It outlines what services were covered, the amount paid, and any remaining balance owed by the patient. It serves as a critical reference for both patients and providers.
Patient Registration Form: Often completed at the first dental visit, this form collects essential information about the patient, including personal details, medical history, and insurance information. It helps the dental office maintain accurate records and facilitate billing.
Consent for Treatment Form: Before any dental procedure, patients are typically required to sign a consent form. This document ensures that patients understand the proposed treatment, associated risks, and costs, thereby protecting both the patient and the provider.
Claim Attachment Form: In some cases, additional documentation is necessary to support a dental claim. This form allows providers to submit extra information, such as radiographs or detailed treatment notes, to justify the services rendered.
Coordination of Benefits Form: When a patient has multiple insurance plans, this form helps determine the order in which claims will be processed. It ensures that all insurers are billed correctly and that patients do not exceed their coverage limits.
Preauthorization Request Form: For certain procedures, dental offices may need to obtain preauthorization from the insurance provider. This form outlines the proposed treatment and requests approval before the services are rendered, helping to avoid unexpected costs for patients.
Medical History Form: This form gathers comprehensive information about a patient's medical background, including any ongoing conditions, medications, and allergies. It is crucial for ensuring safe and effective dental care.
Motor Vehicle Bill of Sale: This essential document formally records the transfer of vehicle ownership in California, providing legal recognition for the transaction. You can find the form [here] (https://toptemplates.info/bill-of-sale/motor-vehicle-bill-of-sale/california-motor-vehicle-bill-of-sale/).
Treatment Plan: A detailed outline of the proposed dental services, including timelines and costs. This document is often shared with the patient and can be submitted to the insurance company for approval or reimbursement.

Understanding these additional forms and documents can significantly enhance the claims process. By ensuring that all necessary paperwork is completed and submitted, both dental providers and patients can work together to navigate the complexities of dental insurance more effectively.