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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.
- Dental Insurance Frequently Asked Questions
My patient was paid directly by the dental plan even after...
- Frequent General Questions Regarding Dental Procedure Codes
14. The insurance company has denied a claim for procedure...
- Dental Insurance Hub: ADA Council's Actions Support Dentist Claims and Record-Keeping
During its May meeting the ADA Council on Dental Benefit...
- CDT
Using these Code Sets, the ADA has developed three dental...
- ADA Dental Claim Form
Object Moved This document may be found here
- Oral Health Topics
The Oral Health Topics section on ADA.org is intended to...
- Research
The ADA Forsyth Institute (AFI) and the ADA Council of...
- Publication Rates
The production director cannot guarantee accommodation of...
- Dental Insurance Frequently Asked Questions
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
Download and print the ADA dental claim form for submitting dental claims to insurance companies or dental benefit plans. The form includes instructions, codes, and spaces for patient, provider, and treatment information.
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…
ADA 2019 Claim Form for Licensees. 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.
