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ADA 2012 Claim Form

Below is an explanation of how each field on the printed ADA 2012 Claim Form is populated.

Note: The requirements for e-claims are different than the requirements for paper claims. Printing a claim does not represent what is sent in an e-claim. Likewise information sent in an e-claim does not necessarily print on a paper claim.

# Field name on form Where entered
1 Type of Transaction
- Statement of Actual Services
- Request for Predeterm/Preauthorization
 
2 Predetermination/Preauthorization Number

Edit Claim window, Predeterm Benefits field

Insurance Company/Dental Benefit Plan Information
3 Company/Plan Name, Address, City, State, Zip Edit Insurance Plan window for insurance plan listed first in Family module.
Other Coverage
4 Dental, Medical  
5 Name of Policyholder/Subscriber in #4 Edit Patient, Last Name, First Name for the patient marked as subsciber on secondary plan.
6 Date of Birth

Edit Patient window, Birth Date field for the patient marked as subsciber on secondary insurance plan.

7 Gender Edit Patient window, Gender field for the patient marked as subsciber on secondary plan.
8 Policyholder/Subscriber ID Edit Insurance Plan window, Subscriber ID (secondary plan)
9 Plan/Group Number Edit Insurance Plan window, Group Num (secondary plan)
10 Patient's Relationship to person named in #5 Edit Insurance Plan window, Relationship to Subscriber (secondary plan)
11 Other Insurance Company/Default Benefit Plan Name, Address, City, State, Zip Edit Insurance Plan window (secondary plan)
Policyholder/Subscriber Information
12 Policyholder/Subscriber Name Edit Patient window for patient marked as subscriber on the primary plan.
13 Date of Birth Edit Patient window for patient marked as subscriber on the primary plan.
14 Gender Edit Patient window for patient marked as subscriber on the primary insurance plan.
15 Policyholder/Subscriber ID Edit Insurance Plan window (primary plan)
16 Plan/Group Number Edit Insurance Plan window, Group Num (primary plan)
17 Employer Name Edit Insurance Plan window (primary plan)
Patient Information
18 Relationship to Policyholder/Subscriber in #12 Edit Insurance Plan window, Relationship to Patient or Edit Claim, Relationship
20 Name Edit Patient window
21 Date of Birth Edit Patient window
22 Gender Edit Patient window
23 Patient ID/ Account # Edit Patient window, Patient Number
Record of Services Provided
24 Procedure Date Procedure Info, Date field
25 Area of Oral Cavity

Procedure Info, a two digit code

26 Tooth System 'JP' indicates ADA's Universal National Tooth Designation system for the USA 1 - 32 for permanent teeth, A - T for primary.
27 Tooth Number or Letter Procedure Info, Tooth Number
28 Tooth Surface Procedure Info, Surfaces
29 Procedure Code Procedure Info, Procedure
29a Diag Pointer

Shows letter (a, b, c, or d) associated with ICD-9 or ICD-10 codes listed in 34a.

29b Qty Procedure Info, Medical tab, Unit Quantity
30 Description Cannot be changed.  Procedure Code Edit.
31 Fee Procedure Info, Amount
31a Other Fees  
32 Total Fee The sum of all Fees.
33 Missing Teeth Information Chart module, Missing Teeth
34 Diagnosis Code List Qualifier Shows B if using ICD-9 codes. Shows AB if using ICD-10 codes. ICD-9 / ICD-10 Diagnosis Codes.
34a Diagnosis Code

Identifies the letter (a, b, c, or d) associated with the ICD-9 or ICD-10 diagnosis codes entered on the Procedure Info, Medical tab.  Only 4 codes allowed per claim.

35 Remarks Edit Claim, General tab, Claim Note
Authorizations
36 Patient/Guardian Signature If the Release of Information box on the Edit Insurance Plan window is checked, 'Signature on File' will show this box.
37 Subscriber Signature  
Ancillary Claim/Treatment Information
38 Place of Treatment Procedure Info window, Misc tab, Place of Service or Edit Claim, General tab.
39 Enclosures  
40 Is Treatment for Orthodontics Edit Claim, General tab, Is for Ortho
41 Date Appliance Placed Edit Claim, General tab, Date of Placement
42 Months of Treatment Remaining Edit Claim, General tab, Months Remaining
43 Replacement of Prosthesis Edit Claim, General tab.
44 Date of Prior Placement Edit Claim, General tab, Prior Date of Placement
45 TreatmentResultingFrom Edit Claim, General tab
46 Date of Accident Edit Claim, General tab, Accident Date
47 Auto Accident State Edit Claim, General tab, Accident State
Billing Dentist or Dental Entity
48 Name, Address, City, State, Zip

Edit Practice Info window, Default Insurance Billing Dentist and Pay To Address.  Or info for the Billing Dentist selected on Edit Claim.

For Clinics, if the provider set as the Treating Dentist is assigned to a clinic, the Billing Dentist by default will be set to the Default Insurance Billing Dentist for that clinic.

49 NPI Edit Provider window, National Provider ID for billing dentist
50 License Number Edit Provider window, State License Number for billing dentist
51 SSN or TIN Edit Provider window, SSN or TIN for billing dentist
52 Phone Number Edit Practice Info window
52a Additional Provider ID Loops through all of the billing provider's Supplemental Provider Identifiers and displays the ID Number of the first one that matches the carrier's Electronic ID. The Electronic ID (Payor ID) entered in the Lists, Provider, Supplemental Provider Identifiers must match the ID listed by the carrier in Lists, Carrier.
Treating Dentist and Treatment Location Information
53 Signed (Treating Dentist), Date

To read "Signature on File", go to Account Module Preferences, Claim Form treating dentist shows Signature on File rather than name.
Edit Provider window for treating dentist, Signature on file box checked.

54 NPI Edit Provider window of treating dentist.
55 License Number Edit Provider window of treating dentist.
56 Address, City, State, Zip Edit Practice Info window
57 Phone Number Edit Practice Info window
58 Additional Provider ID Same as 52a but for the treating dentist.

 

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