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Free Ada Dental Claim Template

The Ada Dental Claim Form is a standardized document used to submit dental claims to insurance companies or dental benefit plans. This form collects essential information about the patient, the policyholder, and the services provided, ensuring that claims are processed efficiently. Completing the form accurately is crucial for timely reimbursement, so take the first step towards managing your dental claims by filling out the form below.

Access Ada Dental Claim Editor Here

Table of Contents

The ADA Dental Claim Form serves as a crucial tool for facilitating the reimbursement process between dental providers and insurance companies. This form encompasses various sections that capture essential information needed to process claims effectively. At the outset, it requires header information that includes the type of transaction being submitted, such as a statement of actual services or a request for preauthorization. Next, details about the policyholder or subscriber, including their name, address, and insurance identification number, must be provided. The form also seeks to establish whether the patient has any other dental or medical coverage, which is vital for coordination of benefits. Patient information is meticulously gathered, detailing their relationship to the policyholder, date of birth, and gender. Furthermore, the record of services section allows dentists to document the procedures performed, including dates, descriptions, and associated fees. Additional authorizations and treatment information ensure that both the provider and the patient are aware of the financial responsibilities involved. Finally, the form requires signatures from both the patient and the treating dentist, affirming the accuracy of the information provided and the consent for payment to be directed to the dental provider. Each component of the ADA Dental Claim Form is designed to streamline the claims process, ensuring that all necessary details are readily available for review and approval by insurance entities.

Document Specifics

Fact Name	Description
Form Purpose	The ADA Dental Claim Form is used to submit claims for dental services to insurance companies or dental benefit plans.
Transaction Types	Claim submissions can include various transaction types, such as a Statement of Actual Services or requests for Predetermination/Preauthorization.
Policyholder Information	Details about the policyholder, including their name, address, and insurance ID, must be provided for accurate claim processing.
Patient Details	Information about the patient, including their relationship to the policyholder and date of birth, is required to link the claim to the correct individual.
Missing Teeth Information	Claimants must indicate any missing teeth on the form, which can affect the coverage and reimbursement for dental procedures.
National Provider Identifier (NPI)	Providers must include their NPI, a unique identifier for dental professionals, ensuring proper identification and processing of claims.
State-Specific Regulations	Compliance with state laws is crucial; for instance, some states may have specific requirements for the completion and submission of the form.

Similar forms

CMS-1500 Form: This form is used for submitting medical claims to insurance companies. Like the ADA Dental Claim form, it requires detailed patient and provider information, including policyholder details and procedure codes.
UB-04 Form: Commonly used for hospital billing, the UB-04 captures patient demographics and services rendered. Similar to the ADA form, it includes sections for insurance information and detailed service descriptions.
Articles of Incorporation Form: To officially launch your corporation in California, it's essential to complete the Articles of Incorporation form, which outlines crucial details about your business. For guidance on filling this out accurately, refer to California PDF Forms.
Dental Claim Form (other variations): Different dental claim forms exist for specific insurance plans. These forms share a similar structure to the ADA form, requiring patient and provider data, as well as service details.
Health Insurance Claim Form (HICF): Used for health insurance claims, this form collects similar information about the patient and services provided, akin to the ADA Dental Claim form.
Medicare Claim Form: This form is specifically for Medicare patients. It gathers similar information, including patient demographics and services rendered, similar to the ADA Dental Claim form.
Workers' Compensation Claim Form: Used for claims related to workplace injuries, this form requires patient and treatment information, paralleling the structure of the ADA Dental Claim form.
Coordination of Benefits (COB) Form: This form is utilized when a patient has multiple insurance plans. It collects details about the primary and secondary insurance, similar to the ADA form's sections on other coverage.
Preauthorization Request Form: Used to obtain approval from insurance before a procedure, this form captures patient and procedure details, much like the ADA Dental Claim form's preauthorization section.

Free Ada Dental Claim File

Ada Dental Claim 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

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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

Understanding Ada Dental Claim

What is the purpose of the ADA Dental Claim Form?

The ADA Dental Claim Form is used to submit claims for dental services to insurance companies or dental benefit plans. It collects essential information about the patient, the policyholder, and the services provided. Completing this form accurately ensures that dental providers receive timely payment for their services and helps patients understand their coverage and potential out-of-pocket expenses.

What information is required on the ADA Dental Claim Form?

To complete the ADA Dental Claim Form, you need to provide detailed information in several sections. This includes header information like the type of transaction, policyholder details, and insurance company information. Additionally, patient information such as name, date of birth, and relationship to the policyholder is required. You must also document the services provided, including procedure dates, tooth numbers, and associated fees. Every field must be filled out unless specified otherwise.

How do I submit the ADA Dental Claim Form?

Once the form is completed, it should be submitted to the appropriate insurance company or dental benefit plan. Ensure that the insurance company’s name and address are visible in a standard #10 window envelope. For claims involving multiple procedures, you may need to attach additional forms. Always keep a copy of the completed form for your records before sending it off.

What should I do if I have secondary insurance?

If you have secondary dental insurance, complete the ADA Dental Claim Form in its entirety and attach the primary payer’s Explanation of Benefits (EOB). This shows the amount paid by the primary insurance. In the remarks section, you can indicate the payment amount from the primary carrier. This ensures that the secondary insurance can process your claim accurately.

What happens if I make a mistake on the ADA Dental Claim Form?

If you realize you've made a mistake after submitting the form, contact the insurance company immediately. They may require you to submit a corrected claim. Always double-check the form for accuracy before submission to avoid delays in processing and payment. Keeping records of all communications and submissions is advisable for reference.

Dos and Don'ts

Do read the entire form carefully before filling it out.
Do ensure that all required fields are completed, including names, addresses, and dates.
Do use the correct format for dates, including the four-digit year.
Do check for any missing teeth and mark them clearly on the form.
Don't leave any required sections blank; incomplete forms can delay processing.
Don't forget to sign and date the form before submission.

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