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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 #9 window envelope (window to the left).
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.
GENERAL INSTRUCTIONS. 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 #9 window envelope (window to the left). Please fold the form using the ‘tick-marks’ printed in the margin.
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.
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….
Comprehensive ADA Dental Claim Form completion instructions are posted on the ADA’s web site (https://www.ADA.org/en/publications/cdt/ada-dental-claim-form). 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
Please download your copy of the ADA 2019 Claim Form and start using this version immediately.
