Fillable Dental Claim Form PATIENT INFORMATION POLICYHOLDER/SUBSCRIBER INFORMATION OTHER

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Dental Claim Form PATIENT INFORMATION POLICYHOLDER/SUBSCRIBER INFORMATION OTHER

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  • 146 other fields

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RECORD OF SERVICES PROVIDED
24. Procedure Date
(MM/DD/CCYY)
25. Area
of Oral
Cavity
26.
Tooth
System
27. Tooth Number(s)
or Letter(s)
28. Tooth
Surface
29. Procedure
Code
29a. Diag.
Pointer
29b.
Qty.
30. Description 31. Fee
1
2
3
4
5
6
7
8
9
10
33. Missing Teeth Information
(Place an “X” on each missing tooth.)
34. Diagnosis Code List Qualier
( ICD-10 = AB )
31a.
Other
Fee(s)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
34a. Diagnosis Code(s)
A
_________________
C
_________________
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17
(Primary diagnosis in “A”)
B
_________________
D
_________________
32. Total Fee
35. Remarks
AUTHORIZATIONS ANCILLARY CLAIM/TREATMENT INFORMATION
36. I have been informed of the treatment plan and associated fees. I agree to be responsible for all
charges for dental services and materials not paid by my dental benet plan, unless prohibited by
law, or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all
or a portion of such charges. To the extent permitted by law, I consent to your use and disclosure
of my protected health information to carry out payment activities in connection with this claim.
X _____________________________________________________________________________
Patient/Guardian Signature Date
38. Place of Treatment
n
(e.g. 11=ofce; 22=O/P Hospital)
(Use “Place of Service Codes for Professional Claims”)
39. Enclosures (Y or N)
40. Is Treatment for Orthodontics?
No (Skip 41-42)
Yes (Complete 41-42)
41. Date Appliance Placed (MM/DD/CCYY)
42. Months of Treatment 43. Replacement of Prosthesis
No
Yes (Complete 44)
44. Date of Prior Placement (MM/DD/CCYY)
37. I hereby authorize and direct payment of the dental benets otherwise payable to me, directly
to the below named dentist or dental entity.
X _____________________________________________________________________________
Subscriber Signature Date
45. Treatment Resulting from
Occupational illness/injury
Auto accident
Other accident
46. Date of Accident (MM/DD/CCYY) 47. Auto Accident State
BILLING DENTIST OR DENTAL ENTITY
(Leave blank if dentist or dental entity is not
submitting claim on behalf of the patient or insured/subscriber.)
TREATING DENTIST AND TREATMENT LOCATION INFORMATION
53. I hereby certify that the procedures as indicated by date are in progress (for procedures that require
multiple visits) or have been completed.
X________________________________________________________________________________
Signed (Treating Dentist) Date
48. Name, Address, City, State, Zip Code
54. NPI 55. License Number
56. Address, City, State, Zip Code
56a. Provider
Specialty Code
49. NPI 50. License Number 51. SSN or TIN
52. Phone
Number
52a. Additional
Provider ID
57. Phone
Number
58. Additional
Provider ID
HEADER INFORMATION
1. Type of Transaction (Mark all applicable boxes)
Statement of Actual Services
Request for Predetermination/Preauthorization
EPSDT / Title XIX
2. Predetermination/Preauthorization Number
DENTAL BENEFIT PLAN INFORMATION
3. Company/Plan Name, Address, City, State, Zip Code
OTHER COVERAGE
(Mark applicable box and complete items 5-11. If none, leave blank.)
4. Dental?
Medical?
(If both, complete 5-11 for dental only.)
5. Name of Policyholder/Subscriber in # 4 (Last, First, Middle Initial, Sufx)
6. Date of Birth (MM/DD/CCYY)
8. Policyholder/Subscriber ID (Assigned by Plan)
9. Plan/Group Number 10. Patient’s Relationship to Person named in #5
Self Spouse Dependent Other
11. Other Insurance Company/Dental Benet Plan Name, Address, City, State, Zip Code
POLICYHOLDER/SUBSCRIBER INFORMATION
(Assigned by Plan Named in #3)
12. Policyholder/Subscriber Name (Last, First, Middle Initial, Sufx), Address, City, State, Zip Code
13. Date of Birth (MM/DD/CCYY) 15. Policyholder/Subscriber ID (Assigned by Plan)
16. Plan/Group Number 17. Employer Name
PATIENT INFORMATION
18. Relationship to Policyholder/Subscriber in #12 Above
Self
Spouse
Dependent Child
Other
19. Reserved For Future
Use
20. Name (Last, First, Middle Initial, Sufx), Address, City, State, Zip Code
21. Date of Birth (MM/DD/CCYY) 23. Patient ID/Account # (Assigned by Dentist)
©2019 American Dental Association
J430 (Same as ADA Dental Claim Form – J431, J432, J433, J434, J430D)
To reorder call 800.947.4746
or go online at adacatalog.org
foldfold
fold
fold
Dental Claim Form
U
7. Gender
U
22. Gender
F
M
14. Gender
M
F
U
M
F
Delta Dental of Michigan
PO Box 9085
Farmington Hills, MI 48333-9085
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 qualied 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/
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Dental Claim Form PATIENT INFORMATION POLICYHOLDERSUBSCRIBER INFORMATION OTHER

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Completed 2 February 2021

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