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 window for insurance plan listed first in Family module.
Other Coverage
4 Dental, Medical
5 Name of Policyholder/Subscriber in #4 Edit Patient Information Window, Last Name, First Name for the patient marked as subscriber on secondary plan.
6 Date of Birth Edit Patient Information window, Birth Date field for the patient marked as subscriber on secondary insurance plan.
7 Gender Edit Patient Information window, Gender field for the patient marked as subscriber 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 Information window for patient marked as subscriber on the primary plan.
13 Date of Birth Edit Patient Information window for patient marked as subscriber on the primary plan.
14 Gender Edit Patient Information window for patient marked as subscriber on the primary insurance plan.
15 Policyholder/Subscriber ID Edit Patient Information window (primary plan)
16 Plan/Group Number Edit Patient Information window, Group Num (primary plan)
17 Employer Name Edit Patient Information window (primary plan)
Patient Information
18 Relationship to Policyholder/Subscriber in #12 Edit Patient Information window, Relationship to Patient or Edit Claim window, Relationship
20 Name Edit Patient Information window
21 Date of Birth Edit Patient Information window
22 Gender Edit Patient Information window
23 Patient ID/ Account # Edit Patient Information window, Patient Number
Record of Services Provided
24 Procedure Date Procedure Info Window, Date field
25 Area of Oral Cavity Procedure Info window, 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 window, Tooth Number
28 Tooth Surface Procedure Info window, Surfaces
29 Procedure Code Procedure Info window, Procedure
29a Diag Pointer Shows letter (a, b, c, or d) associated with ICD-9 or ICD-10 codes listed in 34a
29b Qty Procedures - Medical Tab, Unit Quantity
30 Description Cannot be changed.
31 Fee Procedure Info window, 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.
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.
37 Subscriber Signature If the Assignment of Benefits (pay provider) box on the Edit Insurance Plan window is checked, Signature on File will show.
Ancillary Claim/Treatment Information
38 Place of Treatment Procedures - Misc Tab, Place of Service or Edit Claim window, General tab
39 Enclosures
40 Is Treatment for Orthodontics Edit Claim window, General tab, Is for Ortho
41 Date Appliance Placed Edit Claim window, General tab, Date of Placement
42 Months of Treatment Remaining Edit Claim window, General tab, Months Remaining
43 Replacement of Prosthesis Edit Claim window, General tab
44 Date of Prior Placement Edit Claim window, General tab, Prior Date of Placement
45 TreatmentResultingFrom Edit Claim window, General tab
46 Date of Accident Edit Claim window, General tab, Accident Date
47 Auto Accident State Edit Claim window, General tab, Accident State
Billing Dentist or Dental Entity
48 Name, Address, City, State, Zip 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 Practice Setup
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, check Signature on File on the Edit Provider window and Claim Form treating dentist shows Signature on File rather than name in Account Module Preferences, Insurance tab. To print provider's name, check Signature on File on the Edit Provider window and uncheck Claim Form treating dentist shows Signature on File rather than name in Account Module Preferences, Insurance tab. To leave blank, uncheck Signature on File on the Edit Provider window.
54 NPI Edit Provider window for treating dentist.
55 License Number Edit Provider window for treating dentist.
56 Address, City, State, Zip Edit Provider window
57 Phone Number Edit Provider window
58 Additional Provider ID Same as 52a but for the treating dentist.