⇉

Free Ada Dental Claim PDF Template

The ADA Dental Claim Form is a crucial document used for billing and insurance purposes in dental care. It encapsulates a wide range of information, from personal and insurance details to the specifics of dental treatments provided. Ensuring its accurate completion is essential for the smooth processing of dental claims.

Edit Ada Dental Claim Now

Outline

The complexity of dental procedures and their subsequent billing processes necessitates a clear, structured format for submitting claims, which is where the American Dental Association (ADA) Dental Claim Form gains prominence. Designed to streamline the process of insurance claims for dental services, this form encapsulates crucial information ranging from basic identification details of the policyholder and the patient to the specifics of dental procedures performed, including dates, tooth numbers, and services provided. A key aspect of this form is providing a transparent medium through which transactions—be it actual services rendered or requests for predetermination/preauthorization—can be communicated efficiently. Other significant sections include policyholder and patient information, details about other dental or medical coverage, and a comprehensive record of services provided. Moreover, the form addresses specifics like missing teeth information, authorizations required from the patient or guardian, and detailed billing dentist or dental entity information. It's structured to fit within the administrative expectations of insurance companies, ensuring that vital information like policyholder’s name, address, and the insurance company’s details are clearly visible when placed in a standard #10 window envelope, thus conforming to the ADA’s meticulous standards. This form thereby embodies a critical tool in bridging communication between dental professionals, patients, and insurance entities, ensuring a smoother operational flow in dental health care management.

Document Preview

fold

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

Get PDF Form

Document Attributes

Fact Number	Description
1	The ADA Dental Claim Form includes sections for HEADER INFORMATION, listing various types of transactions such as Statement of Actual Services and Request for Predetermination/Preauthorization.
2	POLICYHOLDER/SUBSCRIBER INFORMATION section requires detailed information about the policyholder or subscriber including name, address, and identification numbers.
3	INSURANCE COMPANY/DENTAL BENEFIT PLAN INFORMATION is to be filled with the name and address of the insurance company or dental benefit plan.
4	The form queries OTHER COVERAGE details to identify if there is any other dental or medical coverage available to the patient.
5	PATIENT INFORMATION captures the relationship of the patient to the policyholder, along with the patient’s name, date of birth, and student status.
6	The RECORD OF SERVICES PROVIDED section is designed to document detailed information about dental services, including procedure dates, tooth numbers, descriptions, and fees.
7	State-specific governing laws apply when completing the form, especially in the context of how information is shared with insurance companies or dental benefit plans, but such specifics must be referred to the individual state’s regulations.

How to Fill Out Ada Dental Claim

Filling out the ADA Dental Claim Form can appear daunting at first glance, but it's a critical step toward ensuring the services rendered by dental professionals are appropriately billed to and reimbursed by the correct insurance company. Each section of the form serves a unique purpose, from providing insurer details to detailing the dental services provided. By breaking down the process into manageable steps, this task becomes less overwhelming. Here's a guide to help you confidently complete the form, ensuring all necessary information is accurately conveyed.

Header Information: Check the appropriate box to indicate the type of transaction: Statement of Actual Services, Request for Predetermination/Preauthorization, or EPSDT/Title XIX. If applicable, enter the Predetermination/Preauthorization Number.
Policyholder/Subscriber Information: In the designated fields, input the policyholder's or subscriber's name, including last, first, middle initial, and suffix, along with their address, city, state, and zip code.
Insurance Company/Dental Benefit Plan Information:
- Write down the Company/Plan Name.
- Provide the Company/Plan Address, City, State, and Zip Code.
Policyholder/Subscriber Info (cont’d):
- Enter the Date of Birth (MM/DD/CCYY).
- Select the Gender (M/F).
- Record the Policyholder/Subscriber ID.
If there is Other Coverage, mark 'Yes' and then:
- Provide the name of the Policyholder/Subscriber in the other dental or medical coverage.
- Fill out their Date of Birth, Gender, Policyholder/Subscriber ID, Plan/Group Number, and Employer Name.
- Detail the Patient’s Relationship to the person named in the Other Coverage.
- List the Other Insurance Company/Dental Benefit Plan Name, Address, City, State, Zip Code.
If 'No', skip to the Patient Information section.
Patient Information:
- Indicate the Relationship to Policyholder/Subscriber.
- State the Student Status (Full-Time, Part-Time, None).
- Enter the Patient's Name, Address, City, State, Zip Code, Date of Birth, Gender, and Patient ID/Account #.
Record of Services Provided: For each dental service provided, list the Procedure Date, Area of Oral Cavity, Tooth Number(s), Tooth Surface, Procedure Code, and Description of Services. Include each service's Fee.
Missing Teeth Information: Indicate any missing teeth by placing an 'X' on the corresponding tooth number.
Calculate and input the Total Fee for services provided and enter any relevant remarks in the Remarks field.
Authorizations and Ancillary Claim/Treatment Information: Read and acknowledge the authorizations regarding treatment plan, fees, and consent for use and disclosure of health information. Complete additional sections as applicable for orthodontic treatment, including Treatment for Orthodontics, Date Appliance Placed, and Months of Treatment remaining. If necessary, indicate if the treatment is a Replacement of Prosthesis and the Date of Prior Placement.
Indicate if the treatment resulted from an Occupational Illness/Injury, Auto Accident, or Other Accident and provide the Date of Accident if applicable.
Final details and signatures: Ensure all sections are thoroughly reviewed and signed by the patient/guardian and subscriber where indicated. Enter any additional information such as Place of Treatment, Number of Enclosures, and specific Treatment Location Information including the Dentist's Name, NPI, License Number, and Contact Information.

After completing these steps, double-check each section for accuracy. This careful review helps to avoid delays in claim processing. Remember, while completing the ADA Dental Claim Form might initially seem complex, a systematic approach simplifies it. This form plays a vital role in facilitating effective communication between dental providers and insurance entities, ultimately ensuring prompt and correct payment for dental services.

More About Ada Dental Claim

Frequently asked questions about the ADA Dental Claim Form can help patients and dental office staff navigate through the intricacies of dental insurance claims. Here, we aim to answer some of your most pressing questions in a way that's both informative and easy to understand.

What exactly is the ADA Dental Claim Form?

The ADA Dental Claim Form is a standardized document used across the dental industry for submitting dental claims to insurance companies. It's designed by the American Dental Association (ADA) and serves as a critical tool for ensuring patients and dental service providers can request and process payments for dental services. The form contains sections for detailing the treatment received, patient information, policyholder/subscriber details, and insurance company/dental benefit plan information, among others.
How do I know if I need to fill out the ADA Dental Claim Form?

Typically, your dentist's office will handle the submission of the ADA Dental Claim Form to your insurance company after your visit. However, there are instances where you, as the patient or policyholder, may need to submit the form yourself—especially if you're seeking reimbursement for out-of-network services or if your dental office does not file claims. If in doubt, consult with your dental office or insurance provider to understand your role in the claims process.
What information do I need to complete the ADA Dental Claim Form?

Filling out the ADA Dental Claim Form requires detailed information spanning various aspects of your treatment and insurance coverage. Key sections include:
- Header Information: Type of transaction and any preauthorization numbers if applicable.
- Policyholder/Subscriber Information: Name, address, and details about the insurance holder.
- Patient Information: The patient’s relationship to the policyholder, student status, and address.
- Record of Services Provided: Details of the dental services rendered, including dates, procedures, and fees.
Ensuring accuracy in these details is crucial for a smooth claims process.
Are there any tips for making sure my ADA Dental Claim is processed efficiently?

A few key practices can help ensure your claim is processed smoothly:
- Accuracy is paramount. Double-check all information for errors before submitting the claim.
- Attach all required documentation, such as an Explanation of Benefits (EOB) if coordinating benefits, or supporting documents like radiographs or oral images if necessary.
- Be aware of the deadlines set by your insurance policy for submitting claims.
- Keep a copy of the completed claim form and any attachments for your records.
Following these steps can help reduce delays and improve the likelihood of your claim being processed favorably.

Common mistakes

When filling out the ADA Dental Claim form, individuals often make mistakes that can delay processing or result in the claim being denied. Understanding and avoiding these common errors is crucial for ensuring the smooth handling of your dental claim.

Incorrect or Incomplete Header Information: The header section requires accurate completion, including the type of transaction and any applicable predetermination/preauthorization numbers. Omitting or incorrectly marking these boxes can lead to processing delays or denials.
Policyholder/Subscriber Information Errors: This section needs the full name, address, date of birth, and ID number of the policyholder. Common mistakes include misspellings, incomplete addresses, and incorrect ID numbers, which can prevent identification by the insurance company.
Failing to Include Other Coverage Details: If there is other dental or medical coverage, details of the secondary policy must be included. Failure to do so or incorrect information can complicate the coordination of benefits.
Misreporting Dental Procedure Information: Each dental procedure must be accurately recorded with the correct date, tooth number, procedure code, and fee. Errors or omissions in this section can result in claim rejection or incorrect benefit payment.

Avoiding these mistakes requires careful review of the claim form before submission, ensuring all information is complete, accurate, and legible. By taking these steps, individuals can help ensure their dental claims are processed efficiently and successfully.

Documents used along the form

In the process of submitting dental claims, a variety of forms and documents often accompany the ADA Dental Claim Form to ensure the claim is complete and processed efficiently. These additional documents play a crucial role in detailing the specifics of the patient’s treatment, coverage, and other pertinent information. Below are descriptions of up to seven common documents that might be used alongside the ADA Dental Claim Form.

Explanation of Benefits (EOB): This document is provided by the insurance company to detail what treatments were covered under the patient's plan, the amount paid by the insurance, and any balance the patient is responsible for.
Treatment Plan: A detailed plan from the dental provider that outlines proposed treatments, expected outcomes, and the estimated costs associated with each procedure.
Prior Authorization Form: Some treatments require prior approval from the insurance company to ensure they are covered under the patient's policy. This form is sent to the insurer before treatment begins.
Radiographs or X-rays: Dental claims often require visual proof of the condition being treated. Radiographs or X-rays are provided to support the necessity of the proposed treatment.
Narrative Report: A written statement by the treating dentist that gives a detailed explanation of the patient's condition, the necessity for the chosen treatment, and any other relevant information.
Itemized Bill: A comprehensive breakdown of all charges associated with the patient's treatment, including each procedure, material costs, and any additional fees.
Privacy and Consent Forms: Given the sensitive nature of health information, forms that document the patient's consent to share their medical data between the dentist and the insurance company are often required.

Collectively, these documents contribute to a well-documented and transparent claims process, facilitating swift and accurate reimbursement for dental care expenses. The importance of these documents can't be overstated, as they provide essential information that supports the claim, ensures compliance with insurance requirements, and assists in the eventual reimbursement process.

Similar forms

The Health Insurance Claim Form (HCFA-1500): Used by physicians and other healthcare providers to bill medical insurance companies, the HCFA-1500 form shares similarities with the ADA Dental Claim Form in its design to facilitate third-party payer reimbursements. Both forms include detailed patient information, provider identifiers, and procedures codes but tailor these categories to their respective medical or dental contexts.
The Universal Claim Form (UCF): This form, employed in pharmacy billing, captures similar information to the ADA Dental Claim Form, like patient demographics, insurance details, and a record of services provided. The main difference lies in the UCF's focus on medication dispensing, illustrating how various sectors of healthcare customize their documentation for specific types of services.
Automobile Insurance Claim Form: This form is used for filing claims related to auto accidents and is akin to the ADA Dental Claim Form in aspects such as collecting policyholder data, insurance company details, and specifics regarding the incident. In cases of dental injuries due to automobile accidents, similar information might be gathered across both forms.
Vision Claim Form: Similar to the ADA Dental Claim Form, vision claim forms used by optometrists and ophthalmologists gather patient and insurance information, detail the services provided (e.g., eye examinations, glasses, or contact lenses), and request reimbursement from insurance carriers. The parallel structure underscores the standardized approach to health service billing.
Property Insurance Claim Form: Though not health-related, this form parallels the ADA Dental Claim Form in its mechanism for reporting and seeking restitution for damages. It captures details about the policyholder, the insurer, and the nature of the claim, drawing a conceptual bridge between property and dental claim processes.
Workers' Compensation Claim Form: This document, used for reporting work-related injuries or illnesses, mirrors the ADA Dental Claim Form in sections that collect employer information, insurance coverage details, and the description of the incident. When dental services are required due to a workplace injury, the similarity in data collection is evident.
Disability Insurance Claim Form: These forms require comprehensive patient information, medical provider details, and a description of the disability, akin to how the ADA Dental Claim Form is structured to include dental procedure codes, patient identifiers, and insurance details for claims related to dental disabilities.
Medicare/Medicaid Claim Forms: Specifically tailored to the billing procedure of these programs, these forms share the ADA Dental Claim Form's objective of facilitating accurate and efficient reimbursement through detailed patient, provider, and service information.
International Travel Insurance Claim Form: Designed for policyholders seeking medical or dental care abroad, these forms resemble the ADA Dental Claim Form in gathering detailed personal and insurance information, services rendered, and a rationale for the claim, emphasizing the importance of comprehensive documentation in international contexts.

Dos and Don'ts

Filling out the ADA Dental Claim form requires attention to detail and an understanding of the specific guidelines that ensure the claim is processed efficiently and accurately. Below are things you should and shouldn't do when completing this form:

Do:

Ensure that all fields, especially those marked as required, are filled out completely. This includes the patient's information, the policyholder's details, and any specifics related to the dental procedure(s) performed.
Include the National Provider Identifier (NPI) for both the billing dentist or dental entity (Item 49) and the treating dentist (Item 54), if applicable. The NPI is crucial for identifying the healthcare provider in a standardized manner.
Use the correct dental provider taxonomy code that specifies the type of dental professional who delivered the treatment. This helps in categorizing the service accurately for the insurance company.
Attach any necessary documentation, such as the primary payer's Explanation of Benefits (EOB) when the claim involves coordination of benefits (COB). This provides clarity on what has been covered and what is being claimed.

Don't:

Leave fields blank unless the instructions explicitly state that it's not required to fill them. Incomplete forms can delay processing and might result in denied claims.
Forget to include the date in the correct format (MM/DD/CCYY) for all date fields. Consistency in date formatting is essential for processing the claim accurately.
Overlook the folding instructions for the claim form. It's designed to display the insurance company’s name and address through a standard #10 window envelope, which aids in proper handling and routing.
Misplace the additional provider identifier information (if applicable). While not the provider's NPI, this identifier may be required by certain insurance plans or under specific state regulations.

Misconceptions

When it comes to handling the ADA Dental Claim Form, there are several common misconceptions that can lead to confusion and errors. Understanding these can help ensure smooth claims processing.

Misconception 1: The form only needs to be completed for complex procedures.

Every dental service, no matter how minor it may seem, requires documentation on the ADA Dental Claim Form. This ensures that the dental benefit plan can evaluate and process the claim appropriately.

Misconception 2: The "Type of Transaction" section is optional.

It's critical to mark the appropriate box in the Type of Transaction section to indicate if you are submitting a statement of actual services provided, a request for predetermination/preauthorization, or if it relates to an EPSDT/Title XIX service. This helps the insurance company understand the purpose of the claim.

Misconception 3: Policyholder information doesn't need to be complete if the patient is not the policyholder.

Complete policyholder/subscriber information is necessary for the insurance company named in the form (item number 3) to properly identify the policy under which the claim is being made, regardless of whether the patient is the policyholder or a dependent.

Misconception 4: Additional provider identifiers aren't necessary if you've already supplied an NPI.

Although the National Provider Identifier (NPI) is crucial, providing other identifiers (like SSN or TIN) can assist with the accurate and timely processing of your claim, especially where specific insurance plans or legacy systems use these identifiers.

Misconception 5: The Remarks field is for extra information of the dentist's choosing.

The Remarks field (item number 35) should be used to provide any additional information necessary to support the claim, such as details pertinent to coordination of benefits, and not left to the discretion of whatever the dentist wishes to add.

Misconception 6: The details about missing teeth are only relevant for denture claims.

Information on missing teeth is vital for a comprehensive understanding of the patient's dental health and history, impacting various treatments, not only dentures. This helps the insurance company in assessing the necessity and eligibility of certain procedures.

Misconception 7: The place of treatment is irrelevant to the claim.

Documenting the place of treatment (item number 38) is essential, especially since certain benefits may vary depending on whether services are rendered in a provider's office, a hospital, or another setting.

Misconception 8: Authorization and consent signatures are not mandatory for processing.

Signatures for authorization of benefits to the dentist and patient/guardian consent (items 37 and 40) are crucial legal requirements. These authorize the payment of benefits directly to the dentist and consent to the use and disclosure of health information for claim processing.

Key takeaways

Filling out the ADA Dental Claim Form correctly is essential for ensuring that dental claims are processed efficiently and accurately by insurance companies. Here are eight key takeaways that can help you complete the form without errors:

Every box in the form should be completed unless specified otherwise. This thorough approach prevents delays in claim processing due to missing information.
The form requires that all dates include the four-digit year, ensuring clarity and preventing misunderstandings about the timing of services.
When the form is being sent to a third-party payer, the name and address of the insurance company or dental benefit plan (found in Item 3) should be visible through a standard #10 window envelope, simplifying the mailing process.
If a claim involves coordination of benefits (COB), the form must be filled out completely, and the primary payer’s Explanation of Benefits (EOB) should be attached, showing the amount paid. This detail helps the secondary payer determine their payment portion.
The National Provider Identifier (NPI) is crucial for the claim form. This unique identifier is assigned by the federal government and distinguishes the provider for HIPAA-covered entities.
In addition to the NPI, an Additional Provider Identifier may be required, particularly if the billing dentist or dental entity is indicated by something other than a Social Security Number (SSN) or Tax Identification Number (TIN).
Provider Specialty Codes need to be accurate to reflect the type of dental professional who delivered the treatment, ensuring that claims are processed according to the correct dental specialty.
If the procedures performed exceed the number of lines available on the claim form, the remaining procedures must be listed on a separate, fully completed claim form, ensuring all services are accounted for in the submission.

Correctly completing the ADA Dental Claim Form is fundamental for dental practices in securing timely payment for services rendered. By adhering to these key points, the process becomes smoother for both the provider and the insurer, facilitating efficient claim processing and reimbursement.

Please rate Free Ada Dental Claim PDF Template Form

Excellent

1 Votes

Other PDF Templates

Do I Need Workers Comp for Myself - Reminds that upon policy cancellation, a new certificate or proof of coverage must be provided.

Form 680 Florida - The form is essential for documenting a child's readiness for school or daycare from an immunization standpoint.