ADA 2012 and 2018 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 Primary insurance electronic ID. 2024 claim form only.
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 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)
11a Other PayerID Other insurance electronic ID. 2024 claim form only.
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 claim form, this 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 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
On the 2012 claim form, this is a checkbox.
On the 2018 claim form, this displaus as M, F, or U.
23 Patient ID/ Account # Edit Patient Information window, Patient Number
On the 2012 claim form, this is the patient's SSN.
Record of Services Provided
24 Procedure Date Procedure, 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 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.
31 Fee Procedure Info window, 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 the Release of Information box on the Edit Insurance Plan window is checked, Signature on File displays.
37 Subscriber Signature If the Assignment of Benefits (pay provider) box on the Edit Insurance Plan window is checked, 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 Automatically checked if an attachment is added to the NEA/Manual Attachments tab in a claim.
39a Date Last SRP 2024 claim form only.
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
On the 2012 claim form, this is number of months remaining.
On the 2018 claim form, this is total months of treatment.
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 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 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 provider shows 'Signature on File' rather than name in Preferences.
  • To print provider's name, check Signature on File on the Edit Provider window and uncheck Claim form treating provider shows 'Signature on File' rather than name in Preferences.
  • To leave blank, uncheck Signature on File on the Edit Provider window.
53a Locum Tenens Dentist When needed, must be manually entered after printing. 2024 claim form only.
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). Address line 2 is not displayed.
56a Provider Specialty Code Provider Edit window, Specialty.
57 Phone Number Practice Setup or Clinic Setup (if using clinics)
58 Additional Provider ID Same as 52a but for the treating dentist.