ADA Claim Forms
Below is an explanation of how each field on the printed ADA 2012, 2018, 2019, and 2024 Claim Forms are 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.
- The 2012 and 2018/2019 claims forms are nearly identical. The few changes are noted in their respective fields.
- The 2024 claim form added new fields. These new fields are noted in their respective fields.
- Also see Claim Addresses for details on entering address and phone information.
| # | Field name on form | Where entered |
|---|---|---|
| 1 | Type of Transaction- Statement of Actual Services- Request for Predeterm/Preauthorization | |
| 2 | Predetermination/Preauthorization Number | Claim, Predeterm Benefits field. |
| Insurance Company/Dental Benefit Plan Information | ||
| 3 | Company/Plan Name, Address, City, State, Zip | Insurance Plan window for insurance plan listed first in Family Module. |
| 3a | Payer ID | 2024 claim form only. Electronic ID from primary insurance plan. |
| Other Coverage | ||
| 4 | Dental, Medical | |
| 5 | Name of Policyholder/Subscriber in #4 | Edit Patient Information, 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. On the 2012 claim form, this is a checkbox for M or F. On the 2018 claim form, this displays as an M, F, or U. On the 2019 claim form, this displays as a checkbox for M, F, or U. |
| 8 | Policyholder/Subscriber ID | From the secondary insurance plan, Edit Insurance Plan window, Subscriber ID. |
| 9 | Plan/Group Number | From the secondary insurance plan, Edit Insurance Plan window, Group Num. |
| 10 | Patient's Relationship to person named in #5 | From the secondary insurance plan, Edit Insurance Plan window, Relationship to Subscriber. |
| 11 | Other Insurance Company/Default Benefit Plan Name, Address, City, State, Zip | From the secondary insurance plan, Edit Insurance Plan window. |
| 11a | Other PayerID | 2024 claim form only. Other insurance electronic ID. |
| 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. On the 2012 claim form, this is a checkbox. On the 2018 and newer claim forms, displays as M, F, or U. |
| 15 | Policyholder/Subscriber ID | Edit Insurance Plan window, Subscriber Information section. |
| 16 | Plan/Group Number | Edit Insurance Plan window, Subscriber Information section. |
| 17 | Employer Name | From the Primary Plan, Edit Patient Information window. |
| Patient Information | ||
| 18 | Relationship to Policyholder/Subscriber in #12 | From the Primary Plan, Edit Insurance Plan window, Relationship to Subscriber. This can be changed on individual claims from Edit Claim window, Relationship. |
| 20 | Name | Edit Patient Information window. |
| 21 | Date of Birth | Edit Patient Information window. |
| 22 | Gender | Edit Patient Information window. On the 2012 claim form, this is a checkbox. On the 2018 and newer claim forms, this displays as M, F, or U. |
| 23 | Patient ID/ Account # | Edit Patient Information window. On the 2012 claim form, this is the patient's SSN. On the 2018 and newer claim forms, this is the Patient Number. |
| Record of Services Provided | ||
| 24 | Procedure Date | Procedure, Date. |
| 25 | Area of Oral Cavity | Procedure Info window, treatment area. Converted to a two-digit code. |
| 26 | Tooth System | JP indicates ADA's Universal National Tooth Designation system for the United States 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 | Procedure - Medical Tab, Unit Quantity. |
| 30 | Description | Cannot be changed. Procedure Info window, Description. |
| 31 | Fee | Edit Claim window, Billed to Ins amount. |
| 31a | Other Fees | |
| 32 | Total Fee | The sum of all fees. |
| 33 | Missing Teeth Information | Chart Module, Missing/Primary 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 - Medical Tab. Only 4 codes allowed per claim. |
| 35 | Remarks | Edit Claim - General Tab, Claim Note. |
| Authorizations | ||
| 36 | Patient/Guardian Signature | If Release of Information is checked on the Edit Insurance Plan window, Signature on File displays. |
| 37 | Subscriber Signature | If Assignment of Benefits (pay provider) is checked on the Edit Insurance Plan window, Signature on File displays. |
| Ancillary Claim/Treatment Information | ||
| 38 | Place of Treatment | Procedure - Misc Tab, Place of Service or Edit Claim window, General tab. |
| 39 | Enclosures | N by default. Automatically marked Y if attachments are added to the NEA/Manual Attachments tab in a claim. |
| 39a | Date Last SRP | 2024 claim form only. Date on the most recently completed D4341 or D4342 procedure. |
| 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/Months of Treatment | Months of Treatment Remaining on the 2012 claim form. Edit Claim window, General tab, Months Remaining. Months of Treatment on the 2018 and newer claim forms. Edit Claim window, General tab, Months Total. |
| 43 | Replacement of Prosthesis | Edit Claim window, General tab, Crown, Bridge, Denture area. |
| 44 | Date of Prior Placement | Edit Claim window, General tab, Prior Date of Placement. |
| 45 | TreatmentResultingFrom | Edit Claim window, General tab, Accident Related. |
| 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 | Edit Claim window, Billing Provider and Practice Setup or Clinic Setup (if using clinics). |
| 49 | NPI | Provider, 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 or Clinic Setup (if using clinics). |
| 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 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 |
|
| 53a | Locum Tenens Dentist | 2024 claim form only. When needed, must be manually entered after printing. |
| 54 | NPI | Edit Provider window for treating dentist. |
| 55 | License Number | Edit Provider window for treating dentist. |
| 56 | Address, City, State, Zip | Practice Setup or Clinic Setup (if using clinics). |
| 56a | Provider Specialty Code | Edit Provider window, Specialty for the treating provider. Converted to an alpha-numeric code. If a Taxonomy Code Override is entered for the provider, this is used instead. |
| 57 | Phone Number | Practice Setup or Clinic Setup (if using clinics). Address line 2 is not displayed. |
| 58 | Additional Provider ID | Same as 52a but for the treating dentist. |