Fillable Form 1.: Dental Claim Form Completion Instructions for

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Form 1.: Dental Claim Form Completion Instructions for

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1
Dental Claim Form Completion Instructions for Members
To file the claim:
1.
2. Attach a
Complete item numbers 1-2, 4-22 and 36-37
signed superbill or statement
3. Mail completed form to:
from your dentist
BlueCross BlueShield of Tennessee
Claims Service Center
1 Cameron Hill Circle Suite 0002
Chattanooga, TN 37402-0002
Note: Save a copy of the completed claim form and superbill/statement for your records.
Header Information
The “header” gives information about the type of claim being filed.
1. Type of Transaction. If services have been performed, check the “Statement of Actual Services” box. If
you are requesting an estimate, check the Predetermination box. If the claim is through the Early and
Periodic Screening, Diagnosis and Treatment Program, mark the box marked “EPSDT/Title XIX”
2. Predetermination/Preauthorization Number. If the services were previously approved, enter the
predetermination claim number.
Insurance Company/Dental Benefit Plan Information
3. Name, Address, City, State, Zip Code. This is for the insurance company/benefit plan information
where you are sending the claim form. This field has already been populated with the BlueCross
BlueShield of Tennessee address.
2
Other Coverage
This area of the claim form is for other dental or medical coverage information. This is needed to check for
coordination of benefits.
4. Other Dental or Medical Coverage. If there is no other coverage, check the box marked “No” and skip
to Item #12. If there is other coverage for the patient, check the box marked “Yes” and complete Items
#5 - 11.
5. Other Insured’s Name (Last, First, Middle, Suffix). Enter the name of the policyholder of the other
insurance.
6. Date of Birth (MM/DD/CCYY). Enter the date of birth of the person listed in Item #5. The date must be
entered with two digits each for the month and day and four digits for the year of birth.
7. Gender. Enter the gender of the person who is listed in Item #5. Check “M” for Male or “F” for Female.
8. Subscriber Identification Number. Enter the ID number of the person who is listed in Item #5.
9. Plan/Group Number. Enter the group number of the other policy.
10. Patient’s Relationship to Other Insured (Check applicable box). Enter the patient’s relationship to the
other (secondary) insured named in Item #5.
11. Other Carrier Name, Address, City, State, Zip Code. Enter the other insurance information.
Policyholder/Subscriber Information
This section is for information about the insured person (policyholder/subscriber) who may or may not be the
patient.
3
12. Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code. Enter the complete name,
address and zip code of the primary insured/employee.
13. Date of Birth (MM/DD/CCYY). A total of eight digits are required in this field; two for the month, two
for the day of the month, and four for the year.
14. Gender. This applies to the primary insured, who may or may not be the patient. Check “M” for male or
“F” for female.
15. Subscriber Identification Number. Enter the subscriber identification number of the primary insured.
This number should be on the ID card.
16. Plan/Group Number. Enter the primary insured’s group plan/policy number. This number should be on
the ID card.
17. Employer Name. If applicable, enter the name of the insured’s employer.
Patient Information
The information in this section of the claim form pertains to the patient.
18. Relationship to Primary Insured (Check applicable box). Mark the appropriate box. If the patient is
also the primary insured, mark the box titled “Self” and skip to Item #36.
19. Student Status. Check “FTS” if patient is a dependent and a full-time student. Check “PTS” if the
patient is a dependent and a part-time student. If neither applies, skip to Item #20.
20. Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code. Enter the complete name
and address of the patient.
21. Date of Birth (MM/DD/CCYY). A total of eight digits are required in this field; two for the month, two
for the day of the month, and four for the year of birth of the patient.
22. Gender. This applies to the patient. Check “M” for male or “F” for female.
Attach a signed superbill/statement from your dentist that reflects the treatment you received and skip
to Item # 36.
(See page 4)
4
Authorizations
This section gives consent for treatment. It also gives permission for the payer to send payment directly to
the dentist.
36. Patient Consent. The patient or guardian must sign and date here. This signature confirms responsibility
for treatment costs and is the release of information for the purpose of collecting payment.
37. Insured’s Signature. This is an authorization for payment of benefits to the dentist. Do not sign this
block if the (out-of-network) dentist has been paid and the payment should to go to the subscriber.
Note: In-network providers must file claims and will receive payment.
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-9 = B; 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
INSURANCE COMPANY/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) 7. Gender
M
F
8. Policyholder/Subscriber ID (SSN or ID#)
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
(For Insurance Company 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) 14. Gender
M
F
15. Policyholder/Subscriber ID (SSN or ID#)
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) 22. Gender
M
F
23. Patient ID/Account # (Assigned by Dentist)
©2012 American Dental Association
J430D (Same as ADA Dental Claim Form – J430, J431, J432, J433, J434)
To reorder call 800.947.4746
or go online at adacatalog.org
foldfold
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Dental Claim Form
The following information highlights certain form completion instructions. Comprehensive ADA Dental Claim Form completion instructions
are printed in the CDT manual. Any updates to these instructions will be posted on the ADA’s web site (ADA.org).
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
benet 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 CDT manual’s instructions.
C. Enter the full name of an individual or a full business name, address and zip code when a name and address eld 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.
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 Benets
(EOB) showing the amount paid by the primary payer. You may also note the primary carrier paid amount in the “Remarks” eld (Item 35).
There are additional detailed completion instructions in the CDT manual.
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 specic 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 elds:
Item 29a – Diagnosis Code Pointer (“A” through “D” as applicable from Item 34a)
Item 34 – Diagnosis Code List Qualier (B for ICD-9-CM; 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 = Ofce; 12 = Home; 21 = Inpatient Hospital; 22 = Outpatient Hospital; 31 = Skilled Nursing Facility; 32 = Nursing Facility
The full list is available online at “www.cms.gov/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 “www.wpc-edi.com/codes/taxonomy”
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Form 1.: Dental Claim Form Completion Instructions for

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Completed 20 September 2021

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