The following information highlights certain form completion instructions. Comprehensive ADA Dental Claim Form completion instructions are posted on the ADA’s web site (https://www.ADA.org/en/publications/cdt/ada-dental-claim-form). GENERAL INSTRUCTIONS A. The form is designed so that the name and address (Item 3) of the third-party payer receiving the claim (insurance company/dental benefit plan) is visible in a standard #9 window envelope (window to the left). Please fold the form using the ‘tick-marks’ printed in the margin. B. Complete all items unless noted otherwise on the form or in the instructions posted on the ADA's web site (ADA.org). C. Enter the full name of an individual or a full business name, address and zip code when a name and address field is required. D. All dates must include the four-digit year. E. If the number of procedures reported exceeds the number of lines available on one claim form, list the remaining procedures on a separate, fully completed claim form. F. GENDER Codes (Items 7, 14 and 22) – M = Male F = Female U = Unknown COORDINATION OF BENEFITS (COB) When a claim is being submitted to the secondary payer, complete the entire form and attach the primary payer’s Explanation of Benefits (EOB) showing the amount paid by the primary payer. You may also note the primary carrier paid amount in the “Remarks” field (Item 35). DIAGNOSIS CODING The form supports reporting up to four diagnosis codes per dental procedure. This information is required when the diagnosis may affect claim adjudication when specific dental procedures may minimize the risks associated with the connection between the patient’s oral and systemic health conditions. Diagnosis codes are linked to procedures using the following fields: Item 29a – Diagnosis Code Pointer (“A” through “D” as applicable from Item 34a) Item 34 – Diagnosis Code List Qualifier (AB for ICD-10-CM) Item 34a – Diagnosis Code(s) / A, B, C, D (up to four, with the primary adjacent to the letter “A”) PLACE OF TREATMENT Enter the 2-digit Place of Service Code for Professional Claims, a HIPAA standard maintained by the Centers for Medicare and Medicaid Services. Frequently used codes are: 11 = Office 12 = Home 21 = Inpatient Hospital 22 = Outpatient Hospital 31 = Skilled Nursing Facility 32 = Nursing Facility The full list is available online at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/Website-POS-database.pdf PROVIDER SPECIALTY This code is entered in Item 56a and indicates the type of dental professional who delivered the treatment. The general code listed as “Dentist” may be used instead of any of the other codes. Category / Description Code Code Dentist A dentist is a person qualified by a doctorate in dental surgery (D.D.S.) or dental medicine (D.M.D.) licensed by the state to practice dentistry, and practicing within the scope of that license. 122300000X General Practice 1223G0001X Dental Specialty (see following list) Various Dental Public Health 1223D0001X Endodontics 1223E0200X Orthodontics 1223X0400X Pediatric Dentistry 1223P0221X Periodontics 1223P0300X Prosthodontics 1223P0700X Oral & Maxillofacial Pathology 1223P0106X Oral & Maxillofacial Radiology 1223D0008X Oral & Maxillofacial Surgery 1223S0112X Provider taxonomy codes listed above are a subset of the full code set that is posted at: http://www.wpc-edi.com/reference/codelists/healthcare/health-care-provider-taxonomy-code-set/