ADA Dental Claim Form Instructions and Information

Submit the completed ADA Dental Claim Form to the dental claim address listed on your plan identification card. You can also send it via email or fax if provided by your insurer. Always verify and follow the specific submission instructions provided by your dental insurance provider.

There are no specific important dates for the ADA Dental Claim Form in 2024 and 2025. Ensure timely submission based on your insurer's requirements.

The ADA Dental Claim Form is a standardized document used to submit claims for dental services provided to patients. This form ensures that all necessary and relevant information is captured for processing dental claims by insurance companies. Accurate and complete information on this form helps expedite the reimbursement process and improves communication between dental providers and insurers. This document includes sections such as primary payer information, patient and subscriber details, records of services provided, and authorizations. Each section must be meticulously filled out to avoid delays in claims processing. By providing a clear and detailed account of the dental services rendered, the form helps insurers make informed decisions about reimbursements. Dentists and dental practices must understand the elements of this form to ensure proper completion and submission. Failing to adhere to the required guidelines can result in denied claims or payment delays. Proper use of the ADA Dental Claim Form contributes to efficient dental practice management and better patient experience.

• 1. Type of Transaction: Indicate whether the transaction is a statement of actual services or a request for predetermination/preauthorization.
• 2. Primary Payer Information: Include details such as the name, address, and contact information of the primary payer.
• 3. Other Coverage: Specify if there's other dental or medical coverage, and provide relevant subscriber and plan details.
• 4. Primary Subscriber Information: Capture the primary subscriber's personal details and plan/group number.
• 5. Patient Information: Enter the patient's relationship to the primary subscriber, student status, and other personal details.
• 6. Record of Services Provided: Detail the dates, procedure codes, and descriptions of the dental services rendered.
• 7. Missing Teeth Information: Report any missing teeth that are relevant to the claim submission.
• 8. Authorizations: Obtain patient and subscriber signatures to authorize the dental claim processing.
• 9. Ancillary Claim/Treatment Information: Provide additional treatment information such as place of treatment and orthodontic details.
• 10. Billing Dentist or Dental Entity: Include billing details such as the dentist or entity's name, address, and identifier.
• 11. Treating Dentist and Treatment Location Information: Capture the treating dentist's details and the location where the treatment was performed.

Failure to submit the ADA Dental Claim Form can result in denied reimbursement and payment delays. Accurate and timely submission is crucial for efficient dental practice management.

• Denied Reimbursement: Insurers may deny claims that are not submitted with complete and accurate information.
• Payment Delays: Delays in submission can lead to longer processing times and delayed payments.

• 1. Dental Services Reimbursement: Use this form to claim reimbursement for dental procedures performed on patients.
• 2. Predetermination/Preauthorization Requests: Submit this form to request predetermination or preauthorization for specific dental treatments.
• 3. Insurance Claims: Submit the form to an insurance company to process dental insurance claims.