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Blank Ada Dental Claim PDF 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 captures essential information about the patient, the services provided, and the insurance coverage involved. Understanding how to fill it out correctly can streamline the claims process and ensure timely payment for dental services.

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Article Guide

The ADA Dental Claim Form serves as a crucial document in the process of seeking reimbursement for dental services. It is structured to collect essential information about the transaction, policyholder, patient, and services provided. The header section requires the type of transaction, such as a statement of actual services or a request for predetermination, ensuring clarity in the claim's purpose. Details about the policyholder, including name, address, and subscriber ID, must be accurately filled out to facilitate communication with the insurance company. The form also addresses any other dental or medical coverage that the patient may have, which is vital for coordinating benefits. Patient information, including their relationship to the policyholder and relevant demographic details, is collected to establish eligibility for coverage. Furthermore, the record of services provided section outlines specific procedures performed, associated fees, and missing teeth information, if applicable. This comprehensive format ensures that all necessary data is presented clearly and concisely, aiding in the timely processing of claims. The form also includes authorizations for treatment and payment, as well as sections for the treating dentist’s information, thus streamlining the claim submission process while maintaining compliance with regulations.

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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

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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

➤ PDF File

Form Specifications

Fact Name	Details
Type of Transaction	The form allows for multiple types of transactions, including a Statement of Actual Services, Request for Predetermination/Preauthorization, and EPSDT/Title XIX.
Policyholder Information	It requires the Policyholder/Subscriber's full name, address, and date of birth.
Insurance Company Details	The form must include the name and address of the insurance company or dental benefit plan.
Other Coverage	If there is other dental or medical coverage, additional information must be provided, including the name of the policyholder.
Patient Information	Details about the patient, including their relationship to the policyholder, must be filled out accurately.
Record of Services Provided	Providers must document the procedure date, area, tooth number, and fees for services rendered.
Authorization Section	The patient or guardian must sign to authorize payment of benefits directly to the dentist or dental entity.
Coordination of Benefits	When submitting to a secondary payer, the primary payer's Explanation of Benefits (EOB) must be attached.
State-Specific Regulations	Each state may have specific laws governing the use of the ADA Dental Claim Form, which should be reviewed for compliance.

Ada Dental Claim: Usage Guidelines

Completing the ADA Dental Claim Form requires careful attention to detail to ensure all necessary information is provided accurately. Following these steps will help streamline the process and facilitate timely processing of the claim.

Type of Transaction: Mark all applicable boxes at the top of the form, including Statement of Actual Services, Request for Predetermination/Preauthorization, and EPSDT/Title XIX.
Predetermination/Preauthorization Number: If applicable, enter the number in the designated space.
Policyholder/Subscriber Information: Fill in the name (last, first, middle initial, suffix) and complete address, including city, state, and zip code.
Insurance Company/Dental Benefit Plan Information: Enter the company or plan name along with its address, city, state, and zip code.
Date of Birth: Provide the policyholder/subscriber's date of birth in MM/DD/CCYY format.
Gender: Mark the appropriate box for male or female.
Policyholder/Subscriber ID: Include either the Social Security Number (SSN) or the ID number.
Other Coverage: Indicate if there is any other dental or medical coverage. If yes, complete the following fields.
Name of Policyholder/Subscriber for Other Coverage: Enter the name of the individual with the other coverage.
Patient Information: Fill out the patient's relationship to the policyholder, student status, date of birth, gender, and ID/account number assigned by the dentist.
Record of Services Provided: Document each procedure with the date, area, tooth number(s), procedure code, description, and fee.
Missing Teeth Information: Mark each missing tooth with an 'X' and ensure the total fee is calculated accurately.
Authorizations: Read and sign the authorization statement, agreeing to be responsible for any charges not covered by the dental benefit plan.
Treating Dentist Information: Include the name, address, and contact information for the treating dentist or dental entity.
Billing Dentist or Dental Entity: If applicable, provide the billing dentist’s information, including NPI and license number.

After filling out the form, review it for accuracy. Ensure that all necessary signatures are obtained. Once everything is complete, submit the form to the insurance company or dental benefit plan as instructed. This will initiate the claims process, allowing for the review and potential reimbursement for the dental services provided.

Your Questions, Answered

What is the ADA Dental Claim Form used for?

The ADA Dental Claim Form is a standardized document used to submit claims for dental services to insurance companies or dental benefit plans. It helps ensure that all necessary information is provided for the processing of claims, facilitating reimbursement for dental care received by patients.

What information is required in the header section of the form?

The header section requires details about the type of transaction, such as whether it is a statement of actual services or a request for preauthorization. Additionally, it includes a space for the predetermination or preauthorization number, if applicable.

How should I fill out the policyholder/subscriber information?

This section must include the policyholder's or subscriber's full name, address, and date of birth. The gender and identification number, either Social Security Number or another ID, must also be provided. Accurate completion of this section ensures that the claim is linked to the correct insurance policy.

What should I do if the patient has other dental or medical coverage?

If the patient has additional coverage, you must complete the sections related to other coverage. This includes providing the name of the policyholder for the other insurance and the relevant details about that plan. If there is no other coverage, simply skip to the patient information section.

How do I document the services provided on the form?

In the Record of Services Provided section, you must enter the procedure date, area, tooth numbers, and a description of the services rendered. Each procedure should be listed clearly, and the associated fees must be documented accurately to facilitate payment processing.

What if the number of procedures exceeds the available lines on the form?

If you have more procedures than can fit on one claim form, you should list the remaining procedures on a separate, fully completed claim form. Each claim should be submitted with the necessary details to avoid delays in processing.

What is the purpose of the authorization section?

The authorization section allows the patient or guardian to acknowledge their understanding of the treatment plan and associated fees. By signing this section, they agree to be responsible for any charges not covered by their dental benefit plan, ensuring transparency in financial responsibilities.

How is the National Provider Identifier (NPI) used on the form?

The NPI is a unique identifier assigned to healthcare providers, including dentists. It must be included in the appropriate sections of the claim form to ensure that the services are correctly attributed to the provider. This identifier is essential for compliance with HIPAA regulations.

What should I do if the treatment is related to an accident?

If the dental treatment results from an accident, you must indicate this in the designated section of the form. You will also need to provide details about the accident, including the date and nature of the incident, which may affect the claim's processing.

Where can I find more information about completing the ADA Dental Claim Form?

Comprehensive instructions for completing the ADA Dental Claim Form can be found in Section 4 of the ADA Publication titled CDT-2007/2008. Updates and additional resources are also available on the ADA's official website, ensuring that you have the most current information for accurate claim submission.

Common mistakes

Failing to mark all applicable transaction types in the header section. It's important to indicate if you're submitting a statement of services, a request for predetermination, or other relevant options.
Not including the predetermination or preauthorization number if applicable. This number is crucial for processing your claim efficiently.
Leaving out the policyholder's name and full address. Ensure you provide the complete details as this is essential for the insurance company to process the claim.
Omitting the patient's relationship to the policyholder. This information helps clarify the connection between the patient and the insurance holder.
Not providing the patient's date of birth in the correct format (MM/DD/CCYY). Incorrect date formats can lead to processing delays.
Failing to fill out the record of services provided section completely. Each procedure must be documented accurately, including dates and fees.
Forgetting to sign the authorization section. Without your signature, the claim cannot be processed.
Neglecting to attach the primary payer's Explanation of Benefits (EOB) when submitting to a secondary payer. This is essential for coordination of benefits.
Not indicating missing teeth properly. Use the designated area to mark any missing teeth, as this can affect the claim outcome.
Leaving out the National Provider Identifier (NPI) for the dentist. This identifier is necessary for identification and billing purposes.

Documents used along the form

When submitting a dental claim, several additional forms and documents may be required to ensure a smooth processing experience. Each document serves a specific purpose and helps provide necessary information to the insurance company or dental benefit plan.

Explanation of Benefits (EOB): This document details what the insurance company has paid for a claim, including any adjustments or denials. It is essential for coordination of benefits when submitting to secondary payers.
Patient Information Form: This form collects detailed information about the patient, including demographics, insurance details, and medical history. It helps the provider understand the patient's coverage and needs.
Authorization for Release of Information: This document allows the dental office to share the patient's medical and dental records with the insurance company. It is crucial for processing claims efficiently.
Pre-Authorization Request Form: Used to obtain approval from the insurance company before certain procedures are performed. This ensures that the treatment is covered under the patient's plan.
Treatment Plan: A detailed outline of the proposed dental procedures, including costs. This document supports the claim by providing context for the services rendered.
Claim Attachment Form: This form is used to submit additional documentation that may be required for specific claims, such as radiographs or models, to support the services provided.
Coordination of Benefits Form: Necessary when a patient has multiple insurance plans. This form helps determine which insurance is primary and how benefits will be coordinated.
Patient Consent Form: A document that confirms the patient understands and agrees to the treatment plan and associated costs. This protects both the provider and the patient.

Using these documents in conjunction with the ADA Dental Claim Form can streamline the claims process and help avoid delays. Ensure all forms are completed accurately to facilitate timely reimbursement.

Similar forms

CMS-1500 Form: Similar to the ADA Dental Claim form, the CMS-1500 is used for submitting medical claims to insurance providers. Both forms require detailed patient and provider information, including names, addresses, and identification numbers. They also have sections for itemizing services rendered and associated fees.
UB-04 Form: This form is utilized for billing institutional providers, such as hospitals. Like the ADA Dental Claim form, it contains sections for patient demographics, insurance information, and a detailed account of services provided, including dates and costs.
Health Insurance Claim Form (HICF): This form is used for various health insurance claims. Both the HICF and the ADA form require information about the policyholder, patient, and the services rendered. They also include sections for authorizations and remarks regarding the services provided.
Medicare Claim Form: Used specifically for Medicare claims, this form shares similarities with the ADA Dental Claim form in that it requires detailed patient and provider information, as well as a breakdown of services and associated costs. Both forms aim to facilitate the claims process for reimbursements.
Workers' Compensation Claim Form: This form is designed for submitting claims related to workplace injuries. Like the ADA form, it requires information about the patient, the nature of the injury, and the services provided. Both forms emphasize the importance of accurate documentation for timely processing.
Auto Accident Claim Form: Used when submitting claims for injuries resulting from car accidents, this form parallels the ADA Dental Claim form in that it includes sections for patient information, treatment details, and insurance coverage. Both forms require thorough documentation to support the claim.
Dental Preauthorization Request Form: Similar to the ADA Dental Claim form, this document is used to request approval from an insurance provider before dental services are rendered. Both forms require detailed patient and provider information, along with specifics about the proposed treatment.
Patient Registration Form: While primarily used for gathering patient information at the start of treatment, this form shares similarities with the ADA Dental Claim form in that it collects demographic details, insurance information, and emergency contacts, all of which are essential for processing claims.

Dos and Don'ts

When filling out the ADA Dental Claim Form, consider the following guidelines to ensure a smooth submission process.

Do complete all required fields accurately.
Do use the full name and address for all individuals and entities.
Do include the four-digit year for all dates.
Do fold the form using the printed tick-marks for proper alignment.
Do attach any necessary documents, such as the primary payer’s Explanation of Benefits if applicable.
Don't leave any required fields blank unless specifically noted as optional.
Don't abbreviate names or addresses; use complete information.
Don't submit more procedures than can fit on one form without using an additional claim form.
Don't forget to sign and date the form where indicated.

Misconceptions

Misconception 1: The ADA Dental Claim Form is only for dental procedures.

This form is versatile. It can also be used for preauthorization requests and other types of dental claims. Understanding its full range of applications can help streamline the claims process.

Misconception 2: All fields on the form must be filled out for every claim.

While it is essential to provide complete information, not all fields are mandatory for every situation. Some sections can be skipped based on specific circumstances, such as when there is no other coverage.

Misconception 3: The form can be submitted without the primary payer’s Explanation of Benefits (EOB).

When submitting a claim to a secondary payer, attaching the primary payer's EOB is crucial. This document outlines what was paid by the first insurer and helps in processing the claim accurately.

Misconception 4: The National Provider Identifier (NPI) is optional for all dentists.

While some dentists may choose to obtain an NPI, it is mandatory for those considered HIPAA covered entities. This identifier is essential for processing claims and ensuring compliance with federal regulations.

Misconception 5: Missing teeth information is not necessary for claims.

Providing details about missing teeth is often required. This information can impact the treatment plan and reimbursement process, making it vital to include on the claim form.

Key takeaways

Ensure all required fields are filled out completely. Missing information can delay processing.
Use the correct transaction type. Indicate whether you are submitting a statement of services, a request for preauthorization, or other options.
Provide accurate policyholder information. Include the full name, address, and subscriber ID.
When indicating other coverage, complete the relevant sections only if applicable.
Document patient information thoroughly, including relationship to the policyholder and date of birth.
List all services provided with precise dates and codes. This ensures clarity for the insurance provider.
Include the total fee for services rendered. Double-check calculations for accuracy.
Sign and date the authorization section. This confirms your agreement to the treatment plan and payment responsibilities.
Attach any necessary documents, such as the primary payer's Explanation of Benefits, when submitting to a secondary payer.