Canada Claim Form

Below is an explanation of how each field on the printed Canadian 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.

Area / Field Name Claim Form Item Used Where Entered
Part 1 - Dentist
Patient PatientLastFirst Edit Patient Information window, last and first name
PatientAddress Edit Patient Information window, Address
PatientAddress2 Edit Patient Information window, Address2
PatientCity Edit Patient Information window, City
PatientST Edit Patient Information window, Province
PatientZip Edit Patient Information window, Postal Code
Unique No. TreatingDentistNPI Provider Edit window, CDA number
Spec. Not entered
Patients Office Account No PatientPatNum Edit Patient Information window, Patient Number
Dentist TreatingDentist Edit Provider window, first name, last name, middle initial, suffix. Displays treating provider on claim.
PayToDentistAddress Edit Practice Info window, Pay To Address. If blank, uses physical treating address.
PayToDentistAddress2 Edit Practice Info window, Pay To Address 2. If blank, uses physical treating address.
PayToDentistCity Edit Practice Info window, Pay To City. If blank, uses physical treating address.
PayToDentistST Edit Practice Info window, Pay To St (province). If blank, uses phyiscal treating address.
PayToDentistZip Edit Practice Info window, Pay To Zip. If blank, uses phyiscal treating address.
TreatingDentistPhoneRaw Edit Practice Info window, Phone
I hereby assign... Patient Assignment Edit Insurance Plan window. When Assignment of Benefits is checked, Signature on File will show.
For Dentist Use Only Remarks Line 1: If predetermination, will show Predetermination Only. If Assignment of Benefits is checked, will show Please pay patient.
Line 2: Will show notes entered in Edit Claim window, General Tab, Claim Note.
I understand that the fee... TotalFee Fee billed to insurance for all items on claim.
Signature of Patient PatientRelease Edit Insurance Plan window. When Release of Information is checked, Signature on File will show.
Date of Service P1Date, etc Procedure Info window, Date
Procedure Code P1Code, etc Procedure sent to insurance
Intl Tooth Code P1ToothNumOrArea, etc Treatment area of procedure code, if any
Tooth Surfaces P1Surface, etc Tooth surface of procedure code, if any
Dentists Fee P1FeeMinusLab, etc Fee billed to insurance for procedure, minus the lab fee, if any.
Laboratory Charge P1Lab, etc Lab fee associated with procedure
Total Charges P1Fee, etc Sum of Dentist's fee and lab charges for the procedure code
Total Fee Submitted TotalFee Sum of Total Charges for all procedures
Part 2 - Employee/Plan Member/Subscriber
Group Policy/Plan No GroupNum Edit Insurance Plan window, Plan Number
Division/Section No DivisionNum Edit Insurance Plan window, Div. No.
Your Name SubscrLastFirst Edit Patient Information window, last and first name of subscriber
Employer EmployerName Edit Insurance Plan window, Employer
Your Cert No or SIN or ID No SubscrIDStrict Edit Insurance Plan window, Subscriber ID
Name of Insurance Agency or Plan PriInsCarrierName Edit Insurance Plan window, Carrier
Your Date of Birth SubscrDOB Edit Patient Information window, Birthdate of subscriber
Part 3 - Patient Information
Patient Relationship to Employee/Plan Member/Subscriber Relationship Edit Insurance Plan window, Relationship to Subscriber
Date of Birth PatientDOB Edit Patient Information window, Birthdate
If child indicate... Student Is Student Edit Patient Information window, Other tab, Eligibility Excep Code 1 or 3
If child indicate... Handicapped Not entered
If student, indicate school College Name Edit Patient Information window, Other tab, Name of school
Patient ID No PatIDFromPatPlan If carrier is Pacific Blue Cross, then: Edit Insurance Plan window, Subscriber ID
If any other carrier, then: Edit Insurance Plan window, Dependent Code
Are any dental benefit or services... No OtherInsNotExists If no secondary coverage
Are any dental benefit or services... Yes OtherInsExists If secondary coverage exists
Policy No OtherInsGroupNum Edit Insurance Plan window, Plan Number (of secondary insurance, if any)
Spouse Date of Birth OtherInsSubscrDOB Edit Patient Information window, Birthdate (of secondary coverage subscriber)
Name of other insuring agency or plan OtherInsCarrierName Edit Insurance Plan, Carrier (of secondary coverage)
Signature of Employee/Plan Member/Subscriber Not entered
Is any treatment required as the result of the accident?No IsNotAccident Edit Claim window, Canadian tab. No accident date entered.
Is any treatment required as the result of the accident?Yes IsAccident Edit Claim window, Canadian tab. Accident date entered.
If Denture, Crown or Bridge…No IsReplacementProsth Edit Claim window, Canadian tab. Maxillary Prosthesis and Mandibular Prosthesis - 1 No and the other not entered or both No
If Denture, Crown or Bridge…Yes IsInitialProsth Edit Claim window, Canadian tab. Maxillary Prosthesis and Mandibular Prosthesis - 1 Yes and the other not entered or both Yes
Is any treatment required for ortho…No IsNotOrtho Edit Claim window, Canadian tab, Treatment Required for Ortho, not checked
Is any treatment required for ortho…Yes IsOrtho Edit Claim window, Canadian tab, Treatment Required for Ortho, checked
Date PatientReleaseDate Displays todays date
Part 4 - Policy Holder / Employer Not entered. If needed, must be filled by hand.