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Fill Out a Valid Ada Dental Claim Form

The Ada Dental Claim Form is a standardized document used by dental providers to submit claims for reimbursement from insurance companies or dental benefit plans. This form collects essential information about the patient, the services rendered, and the insurance coverage involved. Accurate completion of the form is crucial for ensuring timely processing and payment of dental claims; start filling it out by clicking the button below.

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Structure

When navigating the world of dental insurance claims, the ADA Dental Claim Form serves as a critical tool for both dental providers and patients. This comprehensive document facilitates the communication between dental practices and insurance companies, ensuring that claims are processed efficiently. The form includes essential sections that capture header information, policyholder details, patient specifics, and a detailed record of services provided. Each section is meticulously designed to gather pertinent data, such as the type of transaction, policyholder identification, and the relationship of the patient to the policyholder. Additionally, it addresses other coverage options and includes a record of services rendered, complete with procedure dates, descriptions, and associated fees. The form also encompasses authorizations and treatment information, ensuring that both the patient and provider are aligned on the treatment plan and financial responsibilities. By understanding the structure and requirements of the ADA Dental Claim Form, individuals can streamline the claims process, minimize delays, and ultimately improve their experience with dental care and insurance reimbursement.

Common mistakes

Incomplete Header Information: Many individuals neglect to fill out all the required header information. This includes marking the correct type of transaction and providing the predetermination or preauthorization number when applicable. Omitting these details can delay the processing of the claim.
Incorrect Policyholder Information: It is crucial to accurately enter the policyholder's name, address, and identification number. Errors in this section can lead to confusion and may result in the claim being denied.
Failure to Report Other Insurance Coverage: When individuals have additional dental or medical coverage, they must indicate this on the form. Skipping this step can complicate the coordination of benefits and delay payment from the insurance company.
Missing Patient Information: All patient details must be thoroughly completed. This includes the patient's relationship to the policyholder, date of birth, and other relevant identifiers. Incomplete patient information can lead to claim rejection.
Inaccurate Record of Services: When documenting the services provided, it is essential to include the correct procedure dates, tooth numbers, and associated fees. Any discrepancies here can result in underpayment or denial of the claim.

Preview - Ada Dental Claim Form

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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

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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

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Documents used along the form

When submitting a dental claim, the ADA Dental Claim Form is essential, but it often works in conjunction with several other important documents. Each of these forms plays a vital role in ensuring that claims are processed smoothly and accurately. Understanding these documents can help you navigate the claims process more effectively.

Explanation of Benefits (EOB): This document is provided by the insurance company after a claim has been processed. It outlines what services were covered, the amount paid, and any patient responsibility. The EOB is crucial for understanding how much the insurance will cover versus what you will need to pay out-of-pocket.
Patient Consent Form: This form is used to obtain permission from the patient (or guardian) to share their health information with the dental office and insurance company. It ensures compliance with privacy laws and helps protect the patient’s sensitive information.
Horse Bill of Sale Form: When purchasing equine assets, ensure you have the necessary resources for the horse bill of sale form completion to facilitate a smooth transaction.
Dental Treatment Plan: A detailed outline of the proposed dental procedures, this plan is often created by the dentist before treatment begins. It includes the diagnosis, recommended treatments, and associated costs, helping to justify the claim submitted to the insurance company.
Coordination of Benefits (COB) Form: If a patient has multiple insurance plans, this form helps coordinate the claims process between the insurers. It ensures that the claims are submitted correctly and that the patient receives the maximum benefits available from all their coverage.

By familiarizing yourself with these forms, you can better prepare for the dental claims process. Each document plays a key role in ensuring claims are processed efficiently, helping to minimize delays and misunderstandings. Understanding these forms can lead to a smoother experience for both patients and providers.

Similar forms

The ADA Dental Claim Form shares similarities with the CMS-1500 form, which is widely used for medical claims. Both forms require detailed patient information, including demographics and insurance details. The CMS-1500 also captures the type of service rendered, similar to how the ADA form outlines specific dental procedures. Both forms facilitate the claims process by allowing providers to submit necessary information for reimbursement from insurance companies.

Another document that resembles the ADA Dental Claim Form is the UB-04 form, primarily used for hospital billing. Like the ADA form, the UB-04 collects essential patient and insurance information. It also requires a detailed account of services provided, including dates and types of procedures. While the UB-04 is tailored for inpatient and outpatient hospital services, both forms aim to ensure that claims are processed efficiently by providing clear and comprehensive information.

The Dental Insurance Claim Form is another document that parallels the ADA Dental Claim Form. This form is specifically designed for dental claims and includes similar sections for patient information, treatment details, and insurance coverage. Both forms are structured to gather necessary data to facilitate the payment process from insurance providers, highlighting the importance of accurate and complete information in obtaining reimbursement.

The Health Insurance Claim Form (HICF) also shares characteristics with the ADA Dental Claim Form. Both documents require information about the patient, the provider, and the services rendered. They are designed to streamline the claims process and ensure that all relevant details are included for the insurance company’s review. The HICF is typically used for broader health services, while the ADA form focuses specifically on dental care.

The Workers' Compensation Claim Form is another document that bears similarities to the ADA Dental Claim Form. Both forms are used to submit claims for services rendered, with specific sections for patient information and treatment details. However, the Workers' Compensation Claim Form is tailored for injuries sustained in the workplace, requiring additional information related to the accident or injury. Despite these differences, both forms aim to facilitate reimbursement for medical services.

The Pre-Authorization Request Form is comparable to the ADA Dental Claim Form in that both require detailed patient and treatment information. The Pre-Authorization Request is often used to obtain approval from insurance companies before services are rendered. While the ADA form is submitted after services have been provided, both documents emphasize the need for clear communication between providers and insurers regarding treatment plans and costs.

The Medicare Claim Form, also known as the CMS-1450, is another document that is similar to the ADA Dental Claim Form. Both forms gather essential patient and treatment information to facilitate the claims process. The Medicare Claim Form is specifically designed for services covered under Medicare, while the ADA form focuses on dental services. Nevertheless, both forms serve the same purpose of ensuring that claims are accurately submitted for reimbursement.

Among various legal documents, the Mobile Home Bill of Sale stands out as a crucial form for ensuring the proper transfer of ownership of mobile homes. This document not only outlines the specific details related to the sale, such as the identities of the buyer and seller and the description of the mobile home, but it also safeguards the rights of both parties involved in the transaction, similar to how various claims forms protect the interests of healthcare providers and patients.

The Medicaid Dental Claim Form is yet another document akin to the ADA Dental Claim Form. It is specifically designed for dental services covered under Medicaid programs. Like the ADA form, it requires detailed patient information, treatment descriptions, and insurance details. Both forms aim to ensure that claims are processed efficiently and that providers receive timely reimbursement for their services.

Finally, the Electronic Claim Submission Form mirrors the ADA Dental Claim Form in its purpose of facilitating claims processing. This electronic version captures the same essential information as the ADA form but allows for quicker submission and processing through electronic systems. Both forms prioritize the collection of accurate data to streamline the reimbursement process for dental services.

Dos and Don'ts

When filling out the ADA Dental Claim form, consider the following guidelines to ensure a smooth process:

Do provide complete information in all required fields. This includes names, addresses, and dates.
Do use the correct format for dates, ensuring you include the four-digit year.
Don't leave any mandatory fields blank. Incomplete forms may delay processing.
Don't forget to sign the form. A missing signature can result in rejection of the claim.

Key takeaways

Filling out the ADA Dental Claim Form accurately is crucial for ensuring timely processing and payment. Here are key takeaways to consider:

Transaction Type: Clearly mark all applicable transaction types at the top of the form, including services provided and any requests for preauthorization.
Complete Information: Ensure that all required fields are filled out completely, including the policyholder's name, address, and insurance details.
Patient Details: Include comprehensive patient information, such as their relationship to the policyholder and their date of birth.
Record of Services: Accurately document the procedure date, tooth numbers, and associated fees for each service provided.
Missing Teeth: Indicate any missing teeth by placing an 'X' in the appropriate boxes to avoid confusion during processing.
Authorization: Sign the authorization section to allow the dental benefits to be paid directly to the dentist or dental entity.
Coordination of Benefits: If submitting to a secondary payer, attach the primary payer’s Explanation of Benefits (EOB) and note the amount paid in the remarks section.
National Provider Identifier (NPI): Include the NPI for both the treating dentist and the billing dentist to ensure compliance with federal regulations.
Keep Copies: Always retain copies of the completed claim form and any attachments for your records before submission.

Taking these steps will help facilitate the claims process and minimize delays in receiving benefits. Attention to detail is essential.

How to Use Ada Dental Claim

Completing the ADA Dental Claim Form requires careful attention to detail. Each section of the form must be filled out accurately to ensure timely processing of the claim. Following the steps below will guide you through the process of filling out the form correctly.

Begin with the HEADER INFORMATION. Mark all applicable boxes for the type of transaction: Statement of Actual Services, Request for Predetermination/Preauthorization, or EPSDT/Title XIX.
Enter the Predetermination/Preauthorization Number if applicable.
Fill in the Policyholder/Subscriber Information including their name, address, city, state, and zip code.
Provide the Insurance Company/Dental Benefit Plan Information by entering the company/plan name, address, city, state, and zip code.
Include the Date of Birth and Gender of the policyholder/subscriber.
Enter the Policyholder/Subscriber ID (either SSN or ID#).
Indicate if there is Other Dental or Medical Coverage. If yes, complete the relevant fields (5-11).
If applicable, provide the Name of Policyholder/Subscriber for the other coverage.
In the PATIENT INFORMATION section, indicate the relationship of the patient to the policyholder/subscriber.
Fill in the Student Status of the patient.
Provide the Date of Birth and Gender of the patient.
Enter the Patient ID/Account # as assigned by the dentist.
Complete the RECORD OF SERVICES PROVIDED section with the procedure date, area, tooth number(s), procedure code, description, and fee.
In the MISSING TEETH INFORMATION section, mark each missing tooth with an 'X'.
Calculate and enter the Total Fee.
Sign the AUTHORIZATIONS section, confirming awareness of the treatment plan and fees.
Indicate the Place of Treatment and the number of enclosures, if any.
If the treatment involves orthodontics, complete the additional fields related to orthodontics.
Provide the BILLING DENTIST OR DENTAL ENTITY information, including name, address, and NPI.
Complete the TREATING DENTIST AND TREATMENT LOCATION INFORMATION section, including signature and date.

After filling out the form, review all entries for accuracy. Ensure that all required fields are completed. Once confirmed, submit the form to the appropriate insurance company or dental benefit plan for processing. Proper submission will facilitate the claims process and help avoid delays in receiving benefits.