Updated ADA Claim Form Available Here:
The ADA recently updated their dental claim form. You can find a copy of the updated form on the Forms page by selecting the button below, or by logging in to your dentist account and visiting the Documents and Dentist Handbook section.
Tax Identification Number (TIN)
Submit all claims using the billing dentist/dental entity TIN.
If there is a change to the TIN or the name associated, please notify us so we can complete the TIN change on our end as well. It's important to submit the correct TIN based on the date of service. Any claims with a date of service prior to the TIN change should be submitted using the old TIN, and any claims submitted with a date of service after the TIN change should be submitted using the new TIN.
National Provider Identifier (NPI)
The ADA dental claim form provides space for both the NPI Type 2 (business) and the NPI Type 1 (individual). If your office is registered for a Type 2 NPI, please input it in box 49 of the claim form. If no Type 2 NPI is available, leave box 49 blank. Always include the treating dentist's Type 1 NPI in box 54. Making sure your NPI is in the correct place on the claim form can prevent claims processing delays and denials. For more information, or to manage/apply for your individual or organizational NPI, visit nppes.cms.hhs.gov.
Treating Dentist and Location
The name, NPI Type 1 and License Number of the treating dentist must be included in the Treating Dentist and Treatment Location section of the ADA claim form.
The only exception to this is when a substitute dentist is filling in for a dentist who is absent from his/her practice due to illness, injury, birth of a child, etc. (locum tenens).
The owner's name should never be substituted for the name of the dentist who actually performed treatment on the patient. The treatment location should not reflect the home office or billing office unless it reflects the actual place of treatment.