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Fill Out a Valid Ada Dental Claim Template

The Ada Dental Claim Form is a standardized document used to submit claims for dental services to insurance companies or dental benefit plans. This form gathers essential information about the patient, the policyholder, and the services provided, ensuring that claims are processed efficiently. To begin filling out the form, please click the button below.

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Fill Out a Valid Ada Dental Claim Template

Content Overview

Guide to Writing Ada Dental Claim

Completing the ADA Dental Claim Form is essential for processing your dental insurance claims efficiently. Ensure that all required fields are filled out accurately to avoid delays. Follow these steps to complete the form correctly.

Begin with the Header Information. Mark all applicable boxes for the type of transaction at the top of the form.
Enter the Predetermination/Preauthorization Number if applicable.
Provide the Policyholder/Subscriber Information including name, address, and date of birth.
Fill in the Insurance Company/Dental Benefit Plan Information with the company name and address.
Indicate the Policyholder/Subscriber ID and gender.
If applicable, complete the Other Coverage section. If there is no other coverage, skip to the next section.
Provide details about the patient including their Relationship to the policyholder and their Student Status.
Complete the Patient Information section with the patient’s name, address, date of birth, and gender.
Fill in the Record of Services Provided section. Include procedure date, tooth number(s), and fees for each service.
Mark any Missing Teeth Information as required.
Review the Authorizations section. Sign and date the form as necessary.
Complete the Treating Dentist and Treatment Location Information. Include the dentist’s name, address, and NPI.
Finally, ensure all sections are filled out correctly and completely before submitting.

Document Breakdown

Fact Name	Details
Form Purpose	The ADA Dental Claim Form is used to submit dental claims for reimbursement from insurance companies or dental benefit plans.
Required Information	All sections of the form must be completed unless specifically noted otherwise. This includes details about the policyholder, patient, and services provided.
Coordination of Benefits	If a claim is submitted to a secondary payer, the primary payer's Explanation of Benefits (EOB) must be attached to the form.
National Provider Identifier (NPI)	The form requires the NPI of the dentist or dental entity submitting the claim. This identifier is essential for compliance with federal regulations.
State-Specific Laws	Each state may have additional regulations governing dental claims. It's important to review local laws to ensure compliance when submitting the form.

FAQ

What is the purpose of the ADA Dental Claim Form?

The ADA Dental Claim Form is used to submit dental claims to insurance companies or dental benefit plans. It allows dentists to request payment for services rendered to patients. This form collects essential information about the patient, the policyholder, and the services provided, ensuring that the claim is processed efficiently and accurately.

How do I fill out the header information on the form?

In the header section, you need to indicate the type of transaction. You can mark all applicable boxes, such as "Statement of Actual Services" or "Request for Predetermination/Preauthorization." Next, provide the Predetermination/Preauthorization number if available. This information helps the insurance company understand the nature of the claim and process it accordingly.

What information is required from the policyholder or subscriber?

For the policyholder or subscriber, you must provide their full name, address, and date of birth. Additionally, include their gender and Policyholder/Subscriber ID, which can be either their Social Security Number or an assigned ID number. This information is crucial for identifying the insurance coverage applicable to the claim.

What should I include in the patient information section?

The patient information section requires details about the patient, including their relationship to the policyholder (e.g., self, spouse, dependent), date of birth, and gender. You should also provide the patient’s address and any additional insurance information if applicable. This ensures that the claim is associated with the correct individual and their insurance coverage.

How do I report the services provided?

In the "Record of Services Provided" section, you will list each procedure performed. Include the procedure date, tooth number(s), and a description of the services. You must also enter the corresponding fee for each procedure. If multiple procedures exceed the available lines, use a separate claim form to report the additional services.

What if the patient has other dental or medical coverage?

If the patient has other dental or medical coverage, you must complete the relevant sections of the form. This includes providing details about the other insurance plan, such as the policyholder’s name and the plan/group number. Additionally, attach the primary payer’s Explanation of Benefits (EOB) when submitting to the secondary payer, as this is necessary for coordination of benefits.

What authorizations are required on the form?

The form includes several authorizations that must be signed by the patient or guardian. These include consent for treatment and acknowledgment of responsibility for any charges not covered by the dental benefit plan. Additionally, the patient authorizes the payment of benefits directly to the dentist or dental entity, which streamlines the payment process.

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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: