If you’re new to handling dental claims, reading an ADA Dental Claim Form can feel a bit like filing your taxes for the first time. Luckily you can break down a claim form into four main sections that are easy to tackle: Policy, Patient, and Practice.
The Policy section applies to the insurance policy that will cover the procedure, the policyholder, and the insurance company. The Patient section applies to the patient’s information and what procedures are being covered. The Practice section covers your office’s information and the dentist providing treatment.
As you work through the ADA Dental Claim Form, keep in mind that most of this information will be imported from your practice management system if you are submitting claims electronically.
Box 1: The Type of Transaction field indicates to the insurance company if the procedure(s) are completed or if this is a predetermination of the patient’s benefits. Some insurance companies may require you to send a predetermination to evaluate the cost of the procedure.
Box 2: If a predetermination has been sent, use this box to reference the previous claim number.
Box 3: This is the address of the insurance company (payer) that you’re submitting the claim to.
Box 4-11: Secondary/Other Coverage: To be used if the patient’s treatment is covered by more than one insurance policy. Most frequently, this will be a child covered by both parents’ employer benefits. Note: Medicaid is always entered as secondary coverage.
Box 4: Indicates if the secondary coverage is through dental or medical insurance.
Box 5: Name of policyholder/subscriber for secondary policy.
Box 6: Date of birth for policyholder/subscriber for secondary policy.
Box 7: Gender of policyholder/subscriber for secondary policy.
Box 8: Social Security or Identification Number of policyholder/subscriber for secondary policy.
Box 9: Plan or Group Number for secondary policy.
Box 10: Patient’s Relationship to policyholder/subscriber (spouse, child, etc).
Box 11: Address of the insurance company the secondary policy is affiliated with.
Box 12-17: Policyholder/Subscriber Information is where the patient’s primary coverage information will go. The policyholder information may differ from the patient information, likely due to a parent or spouse’s insurance covering the patient’s treatment.
Box 12: Name and address of policyholder/subscriber.
Box 13: Date of birth of policyholder/subscriber.
Box 14: Gender of policyholder/subscriber.
Box 15: Social Security or Identification Number of policyholder/subscriber.
Box 16: Plan or Group Number for policy.
Box 17: Name of policyholder’s employer.
Box 18-23: Patient Information: If the policyholder and patient are not the same person, you’ll use this space to provide the patient’s information. If the policyholder is the patient you can indicate this in Box 18 and leave 19-23 blank, as this information will be redundant to the policyholder.
Box 18: Indicates the patient’s relationship to the policyholder/subscriber (self, spouse, child, other).
Box 19: No longer in use. This space was previously used to indicate student status.
Box 20: Name and address of the patient.
Box 21: Date of birth of patient.
Box 22: Gender of the patient.
Box 23: For your own use if your practice has internal patient ID numbers, will not be referenced by the insurance company.
Box 24: Procedure Date indicates when the treatment performed (date of patient visit). If the claim is being submitted as a predetermination, you’ll leave Box 24 blank.
Box 25: Area of Oral Cavity: Indicates the area of the mouth that received treatment as a two-digit number (see right).
Box 26: Tooth System should have the initials “JP” in it. This indicates that you are using the ADA’s Tooth Designation System (1-32 for permanent teeth and A-T for primary or “baby” teeth).
Box 27: Tooth Number or Letter indicates what teeth are being worked on. If the procedure involves three or fewer teeth, you’ll use the tooth number or letter (1-32 or A-T). If the procedure involves more than three teeth, you’ll use the Cavity Code associated with Box 25.
Box 28: This indicates what surface of the tooth is being worked on (see left).
Box 29: Procedure Code.
Box 30: Description of the procedure. Typically automated by software used to submit claims.
Box 31: Itemized fees for each procedure that are determined by the practice.
Box 33: Used to indicate any missing teeth. This is typically automated by your practice management software.
Box 34: Currently not used by most insurance companies. The Diagnosis Code List Qualifier tells the insurance company which type of procedure code the office is sending.
Box 35: This is used to make any notes regarding the procedure. The remarks are not typically used by insurance companies unless you want to indicate that information may be missing from the attachments.
Box 36-37: Authorizations is where the patient and subscriber will provide a signature to accept treatment and the associated fees. If you submit claims electronically, your software will write “Signature on File” in this field.
Box 38: Place of Treatment indicates where the patient received care. As a dental practice, you will almost always use “11” to indicate that treatment was provided in an office.
Box 39: Enclosures indicates if you are sending any attachments with the claim. This is irrelevant if you submit your claims electronically and the attachments are sent with the claim.
Box 40-42: Box 40 identifies if the procedure was an orthodontic treatment. If this is a yes, Box 41 indicates when the appliance was placed and Box 42 is how long the patient will receive orthodontic treatment.
Box 43-44: Box 43 will indicate if the treatment replaced any fixed or removable prosthesis (typically applied to crowns). If yes, Box 44 will indicate the date of the prior placement of the prosthesis.
Box 45-47: Box 45 will indicate if the patient is receiving treatment due to an accident. If so, Box 46 provides the date of the accident. If it is an auto accident, you’ll indicate the state of the accident in Box 47.
Box 48: Billing Dentist or Dental Entity is essentially your practice’s information and address, either reference the individual dentist’s name or the name of the group/corporation.
Box 49: Group or Organizational NPI (National Provider Identifier) is a unique number assigned by the Federal Government to your practice.
Box 50: If the billing dentist is an individual, enter the dentist’s license number. If a billing entity (group) is submitting the claim, leave blank.
Box 51: If billing dentist is an individual you can provide either their TIN (Tax Identification Number) or SSN (Social Security Number). If a billing entity is submitting the claim, use the group TIN.
Box 52: Phone number of practice.
Box 52a: Additional Provider IDs were more common before NPI (Box 49). Some insurers, like Medicaid, will require the Additional Provider ID.
Box 53-58: Treating Dentist and Treatment Location Information indicates the dentist that provided treatment to the patient. If you’re not part of a group practice, this information will repeat Box 48-52.
Box 53: Signature of treating dentist and date of signature.
Box 54: Individual NPI (National Provider Identifier) for the treating dentist.
Box 55: Treating dentist’s license number.
Box 56: Treating dentist’s address.
Box 56a: Provider Speciality Code indicates the type of dental professional that delivered treatment to the patient.
Box 57: Treating dentist’s phone number.
Box 58: Treating dentist’s Additional Provider ID (see Box 52a description).