ADA 2012 Claim Form
Below is an explanation of how each field on the printed ADA 2012 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.
| # | 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. |
| 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. |
| 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) |
| 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. |
| 15 | Policyholder/Subscriber ID | Edit Patient Information window (primary plan) |
| 16 | Plan/Group Number | Edit Patient Information window, Group Num (primary plan) |
| 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 |
| 23 | Patient ID/ Account # | Edit Patient Information window, Patient Number |
| 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 USA 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 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 Info, 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 will show. |
| 37 | Subscriber Signature | If the Assignment of Benefits (pay provider) box on the Edit Insurance Plan window is checked, Signature on File will show. |
| Ancillary Claim/Treatment Information | ||
| 38 | Place of Treatment | Procedure - Misc Tab, Place of Service or Edit Claim window, General tab |
| 39 | Enclosures | |
| 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 |
| 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 | For clinics, if the provider set as the Treating Dentist is assigned to a clinic, the Billing Dentist by default will be set to the Default Insurance Billing Dentist for that clinic. |
| 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 |
| 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 dentist shows Signature on File rather than name in Billing Module Preferences, Insurance tab. To print provider's name, check Signature on File on the Edit Provider window and uncheck Claim Form treating dentist shows Signature on File rather than name in Billing Module Preferences, Insurance tab. To leave blank, uncheck Signature on File on the Edit Provider window. |
| 54 | NPI | Edit Provider window for treating dentist. |
| 55 | License Number | Edit Provider window for treating dentist. |
| 56 | Address, City, State, Zip | Edit Provider window |
| 57 | Phone Number | Edit Provider window |
| 58 | Additional Provider ID | Same as 52a but for the treating dentist. |