The ADA Dental Claim Form is a standardized document used by dentists to file claims with dental insurance companies for services provided to patients. It includes sections for patient and policyholder information, details of the treatment provided, and insurance coverage specifics. This form ensures that the necessary information for processing dental insurance claims is systematically reported and helps streamline the reimbursement process.
Navigating through the intricacies of the ADA Dental Claim Form is crucial for both dental professionals and patients to ensure the seamless processing of dental claims. This comprehensive form encompasses various sections, each designed to capture detailed information necessary for the accurate adjudication of a dental claim. It starts with specifying the type of transaction, such as a statement of actual services rendered or a request for predetermination/preauthorization. It also requires policyholder/subscriber information, including name, address, and policy details, to correctly identify the insured party. The form further delves into the insurance company or dental benefit plan specifics, aiming to establish the correct conduit for claim submission. For instances involving other coverage, it methodically collects information on any additional dental or medical coverage that could affect the claim processing. The patient information section ensures the correct identification of the individual receiving treatment, including their relationship to the policyholder and student status, if applicable. A detailed record of services provided, including dates, procedures, and fees, is critical for detailing the treatment. For cases of missing teeth, the form even includes a section for logging such information, highlighting the thoroughness required in reporting dental health. With sections also dedicated to authorizations and treatment information, including specifics about the treating dentist and treatment location, the ADA Dental Claim Form stands as a testament to the complexity and comprehensiveness required in the dental claims process. It's a vital tool not only for billing but also for ensuring patients receive the benefits of their dental insurance plans.
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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 requires attention to detail to ensure accurate processing and reimbursement of dental claims. This form is used for submitting dental claims to insurance companies or dental benefit plans for services rendered. Completing this form accurately is important for the timely processing of claims. Below are the steps necessary to properly fill out the form.
After completing these steps, review the form for accuracy and completeness before submission. Fold the form as instructed for mailing in a standard #10 window envelope, ensuring the appropriate section is visible. Accompany this form with any required documentation, such as radiographs or an Explanation of Benefits if coordinating coverage. Proper completion and submission of the ADA Dental Claim Form help facilitate the efficient processing of dental claims.
What is the ADA Dental Claim Form?
The ADA Dental Claim Form is a document used by dentists to submit a claim to an insurance company or dental benefit plan for the reimbursement of dental services provided to a patient. This form is standardized for use in the dental industry and enables dentists to provide necessary details about the dental services provided, including patient information, services rendered, and the fees charged.
When should the ADA Dental Claim Form be used?
This form should be used whenever a dentist provides a service to a patient that is covered under a dental insurance plan, and the dentist seeks reimbursement from the insurance company. It is also used for predeterminations or preauthorizations of services, allowing the insurance company to assess the necessity and cost of the proposed treatments before they are performed.
How can dentists obtain the ADA Dental Claim Form?
Dentists can obtain the ADA Dental Claim Form by ordering them through the American Dental Association's website at www.adacatalog.org or by calling 1-800-947-4746. Additionally, many dental practice management software systems include electronic versions of the form that can be filled out and submitted digitally.
What information is required on the ADA Dental Claim Form?
The form requires comprehensive information to be filled out, including the type of transaction (e.g., statement of actual services or request for predetermination/preauthorization), policyholder/subscriber information, insurance company or dental benefit plan information, patient information, details of the dental service provided including procedure codes and fees, and any other coverage information. It’s crucial that all sections applicable to the specific dental service are completed accurately to ensure the smooth processing of the claim.
Can the ADA Dental Claim Form be submitted electronically?
Yes, the ADA Dental Claim Form can be submitted electronically. Many dental practices use electronic data interchange (EDI) systems to submit these forms directly to insurance companies or dental benefit plans. This method is efficient and reduces the processing time of claims. However, practices must ensure they comply with HIPAA regulations when submitting any patient information electronically.
What are the common mistakes to avoid when filling out the ADA Dental Claim Form?
Common mistakes include leaving required fields blank, entering incorrect patient or policyholder information, failing to attach necessary documentation (e.g., radiographs or a primary payer’s Explanation of Benefits for coordination of benefits), and using outdated procedure codes. Careful review of the form before submission can prevent delays in claim processing.
Where can I find more information on how to correctly complete the ADA Dental Claim Form?
More detailed instructions on how to correctly fill out the ADA Dental Claim Form can be found in Section 4 of the ADA Publication titled CDT-2007/2008. Additionally, the ADA’s website, www.ada.org/goto/dentalcode, provides updates and further guidance on completing the form, including any recent changes to the form or instructions.
When people fill out the ADA Dental Claim form, common mistakes can lead to delays in processing or even claims being denied. One significant error is not checking the correct Type of Transaction box at the top of the form. This section is crucial because it tells the insurance company the purpose of the submission, whether it's a claim for services already received or a request for predetermination/preauthorization of services. Selecting the wrong option or forgetting to mark any box can confuse the insurer about the nature of the submission.
Another area often filled out incorrectly is the Policyholder/Subscriber Information. People sometimes enter incomplete or inaccurate details in this section. It's essential to include the full name (with the correct suffix), address, city, state, and zip code as listed with the insurance company. Any discrepancies in this information can make it difficult for the insurance company to identify the policyholder, potentially delaying the claim process.
In addition, failure to accurately complete the Other Coverage section can also cause problems. If there's additional dental or medical coverage, this part of the form needs to be filled out entirely, detailing the secondary insurance. Skipping this section or not providing complete information about other insurance policies can lead to issues with coordination of benefits, where insurance companies determine the order in which they're responsible for payment.
Last but certainly not least, a common mistake occurs in the Record of Services Provided section. Individuals often forget to list all of the necessary details for each service, including the date of service, tooth number(s), and the procedure codes. Omitting or inaccurately recording this information can lead to the insurance company not fully understanding the services provided, which may result in a denial of the claim or additional requests for information that delay payment.
The successful processing of dental claims often requires the completion and submission of multiple forms and documents beyond the ADA Dental Claim Form. These additional documents ensure the comprehensive verification of the claim, the patient's eligibility for insurance benefits, and the specific details of the dental procedures performed. Below is an overview of other commonly used forms and documents in conjunction with the ADA Dental Claim Form.
These documents collectively play a crucial role in the dental claim process. They not only facilitate a smoother transaction between dental practitioners and insurance companies but also ensure transparency, accuracy, and the provision of necessary dental care according to policyholder benefits. Understanding these documents and their purposes can significantly aid in navigating the complexities of dental insurance claims, ultimately leading to a more efficient and effective process for patients and providers alike.
The ADA Dental Claim Form shares similarities with the Medical Insurance Claim Form, commonly known as the CMS-1500. Both forms are essential for processing insurance claims, albeit for different types of healthcare services – dental for ADA and general medical for CMS-1500. They collect comprehensive patient and provider information, insurance coverage details, and specifics about the services provided, including dates and fees, to support the insurance claim process. The standardized format of these forms facilitates the submission, processing, and payment of claims by insurance companies, ensuring the necessary data is presented clearly and concisely.
Another document akin to the ADA Dental Claim Form is the Workers' Compensation Claim Form. When a dental injury is job-related, this form comes into play, much like the ADA form is used for dental services in general circumstances. Both forms require detailed information on the patient, the nature of the injury or condition, details of the treatment provided, and the treating practitioner's information. They differ primarily in their focus, with the Workers' Compensation Claim Form geared towards injuries sustained in the workplace, necessitating details about the employment and incident specifics.
The Pharmacy Benefit Management (PBM) Claim Form also shares functionality with the ADA Dental Claim Form, although it pertains to pharmaceutical services. Both serve as a bridge between healthcare providers and insurance companies, ensuring that the services rendered are reimbursed. They collect information on the patient, the service provider, the services or products furnished, and the costs incurred. While the ADA form is specific to dental services, the PBM form focuses on medication-related claims, underlining the specialized nature of each form in facilitating the insurance claim process for different healthcare sectors.
Lastly, the Health Insurance Portability and Accountability Act (HIPAA) Authorization Form, although not a claim form, complements the ADA Dental Claim Form in the insurance claims process. It is a legal document that grants insurance companies access to a patient's medical records and other health information necessary to process claims. The ADA form, with the patient's consent, allows the sharing of dental treatment information with insurance providers to substantiate the claim, highlighting the interconnected role of consent and privacy in the healthcare and insurance industries.
Correctly filling out an ADA Dental Claim form is crucial for the timely processing of dental insurance claims. There are specific dos and don'ts that individuals must follow to ensure their claims are not delayed or denied due to errors in the submission process.
When it comes to dental care, understanding how to properly fill out claim forms is crucial for both patients and dental practitioners. The American Dental Association (ADA) Dental Claim Form is a standardized document widely used to submit dental claims to insurance providers. However, there are several misconceptions about completing and submitting these forms. Let's clear up ten of the most common misunderstandings:
Contrary to this belief, the ADA Dental Claim Form can be used for submitting claims to a variety of dental benefit plans, including but not limited to traditional insurance carriers, dental service plans, and government programs such as Medicaid.
While the form itself is a paper document, many insurance providers and dental offices accept and prefer digital submissions, usually through electronic dental claims submission services or clearinghouses.
The instructions clearly state that not all items need to be completed for every claim. The necessity of filling out each section depends on the specific circumstances of the dental service and the requirements of the dental benefit plan.
The form asks for a Patient ID/Account #, which can be assigned by the dentist and does not necessarily have to be the patient’s SSN. SSN usage is discouraged for privacy reasons.
This number is only required if the services provided need preauthorization. For routine or emergency services that don't require preauthorization, this field can be left blank.
The ADA Dental Claim Form includes sections for detailing secondary or tertiary insurance coverage, making it fully capable of handling coordination of benefits (COB).
An NPI is a requirement for all HIPAA-covered entities. This unique identifier must be provided on the claim form for it to be processed.
The "Remarks" section (Item #35) is an important part of the form, allowing for the inclusion of additional information that can be critical for claim processing and understanding the context of the dental treatment.
For treatments involving prosthetics, orthodontics, or oral surgery, providing accurate missing teeth information (using the chart provided on the form) is essential for appropriate claims processing.
The form and its completion instructions are periodically updated. Practitioners and patients should refer to the ADA’s website or their dental benefits provider to ensure they are using the most current version and following the latest guidelines.
By debunking these misconceptions, dental professionals and patients can ensure that claim submissions are more accurate and less likely to be rejected due to errors. It's always important to consult with the specific dental benefit plan or provider for their requirements, as they can vary. Understanding the correct use of the ADA Dental Claim Form is a key component in the financial aspect of dental care and services.
Understanding the ADA Dental Claim form is essential for ensuring timely and accurate processing of dental insurance claims. Here are some critical takeaways to keep in mind:
Each of these points plays a significant role in the claim's journey through the insurance system. By ensuring that the ADA Dental Claim form is accurately and thoroughly completed, dental professionals can help minimize issues that lead to claim rejections or delays. This, in turn, facilitates a smoother process for both the provider and the patient.
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