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Check out the ADA Online Store for Dental Claim Form (2024 Version) Downloadable PDF.
The ADA Dental Claim Form provides a common format for reporting dental services to a patient's dental benefit plan. ADA policy promotes use and acceptance of the most current version of the ADA Dental Claim Form by dentists and payers.
Comprehensive ADA Dental Claim Form completion instructions are printed in the CDT manual. Any updates to these instructions will be posted on the ADA’s web site (ADA.org).
The form supports reporting up to four diagnosis codes per dental procedure. This information is required when the diagnosis may affect claim adjudication when specific dental procedures may minimize the risks associated with the connection between the patient's oral and systemic health conditions.
The ADA Dental Claim Form was last structurally revised in 2012 to incorporate key data content changes that enables diagnosis code reporting that was also incorporated into the now current version of the HIPAA standard (837D v5010) electronic dental claim.
Comprehensive ADA Dental Claim Form completion instructions are printed in the CDT manual. Any updates to these instructions will be posted on the ADA’s web site (ADA.org).
The ADA Dental Claim Form was revised in 2019 with editorial changes to form captions and check box options for gender (M, F and U) to be consistent with the HIPAA standard electronic dental claim (837D). This is the most recent version of the form…
