01 American Dental Association Claim Form Completion Instructions COMPLETING THE ADA CLAIM FORM The following instructions explain how to complete the ADA Claim Form and whether a field is Required, Required if applicable, or Not required. Use of the new ADA 01 form will be mandatory effective 8/1/14. 1. Type of Transaction Required Check statement of actual services and EPSDT/Title XIX if claim is for a recipient under age 1. If requesting a predetermination or preauthorization, check the appropriate box.. Predetermination/Preauthorization Required if applicable Enter the appropriate code ( A or V ) to indicate whether this claim is a resubmission of a denied claim, an adjustment of a paid claim, or a void of a paid claim. Enter the Claim Reference (CRN) of the denied claim being resubmitted or the paid claim being adjusted or voided in the field labeled "Original Reference No." Section 3 11 are to be completed when there is other coverage (TPL) for the recipient. 3. Company/Plan Name, Address, City, State, Zip Required if applicable 4. Other Dental or Medical Coverage Required Check appropriate box to indicate whether recipient has third party coverage. 5. Name of Policyholder/Subscriber Required if applicable 6. of Birth Required if applicable 7. Gender Required if applicable 8. Subscriber Identifier Required if applicable 9. Plan/Group Required if applicable 10. Relationship to Primary Subscriber Required if applicable 1
11. Other Carrier Name, Address Required if applicable HEADER INFORMATION 1 Type of Transaction (Mark all applicable boxes) Statement of Actual Services Request for Predetermination/Preauthorization EPSDT / Title XIX Predetermination/Preauthorization 0300100431 INSURANCE COMPANY/DENTAL BENEFIT PLAN INFORMATION 3 Company/Plan Name, Address, City, State, Zip OTHER COVERAGE (Mark applicable box and complete 5-11 for dental only) 4 Dental? Medical? (if both, complete 5-11 for dental only) 5 Name of Policyholder/Subscriber in #4 (Last, First, Middle Initial, Suffix) 6 of Birth 7 Gender M F 8 Policyholder/Subscriber ID (SSN or ID#) 9 PLAN/GROUP INFORMATION 10 Patient s Relationship to Person Named in #5 Self Spouse Dependent Other 11 Other Insurance Company/Dental Benefit Plan Name, Address, City, State, Zip 1. Primary Subscriber Name and Address Required Enter recipient's last name, first name, and middle initial as shown on the AHCCCS ID card. Enter the recipient s address. POLICYHOLDER/SCRSCRIBER INFORMATION (For Insurance Company Named in #3) 1 Policyholder/Subscriber Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Earp, Wyatt H. 13 E OK Corral Tombstone, AZ 85638 13 of Birth 14 Gender M F 15 Policyholder/Subscriber ID (SSN or ID#) 15 Plan/Group 17 Employer Name
13. of Birth Required Enter the recipient s date of birth. POLICYHOLDER/SCRSCRIBER INFORMATION (For Insurance Company Named in #3) 1 Policyholder/Subscriber Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Earp, Wyatt H. 13 E OK Corral Tombstone, AZ 85638 13 of Birth 08/4/1851 14 Gender M 15 Plan/Group 17 Employer Name F 15 Policyholder/Subscriber ID (SSN or ID#) 14. Gender Required Check the appropriate box to indicate the patient s gender. POLICYHOLDER/SCRSCRIBER INFORMATION (For Insurance Company Named in #3) 1 Policyholder/Subscriber Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Earp, Wyatt H. 13 E OK Corral Tombstone, AZ 85638 13 of Birth 08/4/1851 14 Gender X M F 15 Plan/Group 17 Employer Name 15 Policyholder/Subscriber ID (SSN or ID#) 15. Subscriber Identifier Required Enter the recipient's AHCCCS ID number. Contact the AHCCCS Verification Unit if there are questions about eligibility or the AHCCCS ID number. POLICYHOLDER/SCRSCRIBER INFORMATION (For Insurance Company Named in #3) 1 Policyholder/Subscriber Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Earp, Wyatt H. 13 E OK Corral Tombstone, AZ 85638 13 of Birth 08/4/1851 14 Gender X M F 15 Policyholder/Subscriber ID (SSN or ID#) A1345678 3
16 Plan/Group 17 Employer Name 16. Plan/Group Not required 17 Employer Name Not required 18. Relationship to Primary Subscriber Not required 19. Reserved for Future Use Not required 0. Name Not required 1. of Birth Not required. Gender Not required 3. Patient ID/Account Required This is a number that you have assigned to uniquely identify this claim in your records. AHCCCS will report this number in correspondence, including the Remittance Advice, to provide a cross-reference between the AHCCCS CRN and your own accounting or tracking system. PATIENT INFORMATION 18 Relationship to Policyholder/Subscriber in #1 Above 19 Reserved for Future Self Spouse Dependent Child Other Use 0 Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip 1 of Birth Gender M F 3 Patient ID/Account # (Assigned by Dentist) WEARP5678 4. Procedure Required Enter the procedure date in MM/DD/YYYY format. 4 Procedure 1 10/10/013 5 Area 6 Tooth 7 Tooth (s) 8 Tooth 9 Procedure 9a Diag 9b 4
5. Area Required Enter the code for the area of the oral cavity. Area 00 entire oral cavity 01 maxillary arch 0 mandibular arch 10 upper right quadrant 0 upper left quadrant 30 lower left quadrant 40 lower right quadrant Do not report the applicable area of the oral cavity when the procedure either: 1) incorporates a specific area of the oral cavity in its nomenclature, such as D5110 complete denture maxillary; or ) does not relate to any portion of the oral cavity, such as D90 deep sedation/general anesthesia first 30 minutes. 4 Procedure 1 10/10/013 10 5 Area 6 Tooth 7 Tooth (s) 8 Tooth 9 Procedure 9a Diag 9b 6. Tooth Required Enter JP when designating teeth using the ADA s Universal/National Tooth Designation system. Enter JO when using ANSI/ADA/ISO Specification No. 3950. 4 Procedure 5 Area 1 10/10/013 10 JP 6 Tooth 7 Tooth (s) 8 Tooth 9 Procedure 9a Diag 9b 5
7. Tooth (s) Required Enter the tooth number when the procedure directly involves a tooth. Use commas to separate individual tooth numbers. If a range of teeth is involved, use a hyphen to separate the first and last tooth in the range. 4 Procedure 5 Area 6 Tooth 1 10/10/013 10 JP 13 7 Tooth (s) 8 Tooth 9 Procedure 9a Diag 9b 8. Tooth Required Designate tooth surface(s) when the procedure directly involves one or more tooth surfaces. Buccal Distal Facial (or labial) Incisal Lingual Mesial Occlusal B D F I L M O 4 Procedure 5 Area 6 Tooth 7 Tooth (s) 1 10/10/013 10 JP 13 B 8 Tooth 9 Procedure 9a Diag 9b 9. Procedure Required Enter the appropriate procedure code from the CDT-4 Manual 4 Procedure 5 Area 6 Tooth 7 Tooth (s) 8 Tooth 9 Procedure 1 10/10/013 10 JP 13 B D140 9a Diag 9b 6
9a Diagnosis Required Enter the letter(s) from Item 34 that identify the diagnosis code(s) applicable to the dental procedure. List the primary diagnosis pointer first. 4 Procedure 5 Area 6 Tooth 7 Tooth (s) 8 Tooth 9 Procedure 1 10/10/013 10 JP 13 B D140 A 9a Diag 9b 9b Quantity Required Enter the number of times (01-99) the procedure identified in Item 9 is delivered to the patient on the date of service shown in Item 4. The default value is 01. 4 Procedure 5 Area 6 Tooth 7 Tooth (s) 8 Tooth 9 Procedure 9a Diag 1 10/10/013 10 JP 13 B D140 A 01 9b 30. Description Required Enter the description of the procedure code billed in Field 9. 4 Procedure 5 Area 6 Tooth 7 Tooth (s) 8 Tooth 9 Procedure 9a Diag 9b 1 10/10/013 10 JP 13 B D140 A 01 Amalgam; one surface, primary or permanent 31. Fee Required Enter the full fee for the procedure code billed in Field 9. 1. A full fee is the fee for a service that is set by the dentist, which reflects the costs of providing the procedure and the value of the dentist s professional judgment.. A contractual relationship does not change the dentist s full fee. 3. It is always appropriate to report the full fee for each service reported to a third-party payer. 7
4 Procedure 5 Area 6 Tooth 7 Tooth (s) 8 Tooth 9 Procedure 9a Diag 9b 1 10/10/013 10 JP 13 B D140 A 01 Amalgam; one surface, primary or permanent $90.00 31a. Other Fees Not required 3. Total Fee Required Enter the total of all fees in Field 31. 33 Missing Teeth Information (Place an X on each missing tooth) 34 Diagnosis List Qualifier ICD-9=B-10=AB 31a Other 1 3 4 5 6 7 8 9 10 11 1 13 14 15 16 34a Diagnosis (s) A C Fees 3 31 30 9 8 7 6 5 4 3 1 0 19 18 17 (Primary diagnosis in A B D 3 Total Fees 35 Remarks $90.00 34. Missing Teeth Required Mark all missing teeth. 33 Missing Teeth Information (Place an X on each missing tooth) 34 Diagnosis List Qualifier ICD-9=B-10=AB 31a Other 1 3 4 X 6 7 8 9 10 11 1 13 14 15 16 34a Diagnosis (s) A C Fees 3 31 30 9 8 7 6 5 4 3 1 0 19 18 17 (Primary diagnosis in A B D 3 Total Fees 35 Remarks $90.00 35. Remarks Not required 36. Parent/Guardian Signature and Not required 37. Subscriber Signature and Not required 8
38. Place of Treatment Required Enter the -digit Place of Service for Professional Claims, a HIPAA standard. Frequently used codes are listed below. All current codes are available online from the Centers for Medicare and Medicaid Services (search for CMS place of service codes downloads). Place of Treatment 11 Office 1 Home 1 Inpatient Hospital Outpatient Hospital 31 Skilled Nursing Facility 3 Nursing Facility ANCILLARY CLAIM/TREATMENT INFORMATION 38 Place of Treatment 11 (e.g. 11 = office; =O/P Hospital) 39 Enclosures (Y or N) (Use Place of Service s for Professional Claims 40 Is Treatment for Orthodontics 41 Appliance Place No (Skip (41-4) Yes (Complete 41 4 Months of Treatment Remaining 45 Treatment Resulting from 43 Replacement of Prosthesis No Yes (Complete 44) 44 of Prior Placement Occupational illness/injury Auto Accident Other Accident 46 of Accident 47 Auto Accident State 39. of Enclosures Required if applicable 40. Is Treatment for Orthodontics? Required if applicable 41. Appliance Placed Required if applicable 4. Months of Treatment Remaining Required if applicable 9
43. Replacement of Prosthesis Required Check the appropriate box. If Yes is checked, complete Field 44. ANCILLARY CLAIM/TREATMENT INFORMATION 38 Place of Treatment 11 (e.g. 11 = office; =O/P Hospital) 39 Enclosures (Y or N) (Use Place of Service s for Professional Claims 40 Is Treatment for Orthodontics 41 Appliance Place No (Skip (41-4) Yes (Complete 41 4 Months of Treatment Remaining 45 Treatment Resulting from 43 Replacement of Prosthesis X No Yes (Complete 44) 44 of Prior Placement Occupational illness/injury Auto Accident Other Accident 46 of Accident 47 Auto Accident State 44. of Prior Placement Required if applicable If Yes is checked in Field 43, enter the date of prior placement in MM/DD/YYYY format. 45. Treatment Resulting From Required if applicable Check the appropriate box, as applicable. 46. of Accident Required if applicable Enter the date in MM/DD/YYYY format. 47. Auto Accident State Required if applicable Enter the name of the state where the accident occurred. 48. Billing Dentist/Dental Entity Name and Address Required Enter the name and address of the billing dentist or dental entity. BILLING DENTIST OR DENTAL ENTITY (Leave blank if dentist or dental entity is not submitting claim on behalf of the patient or insured/subscriber.) 48 Name, Address, City, State, Zip Holliday, John H. 13 E Main Street Scottsdale, AZ 855 49 NPI 50 License 51 SSN or TIN 5 Phone 5a Additional 10
49. NPI Required Enter the appropriate NPI of the billing dentist or dental entity. BILLING DENTIST OR DENTAL ENTITY (Leave blank if dentist or dental entity is not submitting claim on behalf of the patient or insured/subscriber.) 48 Name, Address, City, State, Zip Holliday, John H. 13 E Main Street Scottsdale, AZ 855 49 NPI 65431 5 Phone 50 License 51 SSN or TIN 5a Additional 50. License Required Enter the license number of the billing dentist or dental entity. BILLING DENTIST OR DENTAL ENTITY (Leave blank if dentist or dental entity is not submitting claim on behalf of the patient or insured/subscriber.) 48 Name, Address, City, State, Zip Holliday, John H. 13 E Main Street Scottsdale, AZ 855 49 NPI 65431 5 Phone 50 License 987-65431 5a Additional 51 SSN or TIN 11
51. SSN or TIN Required Enter the Social Security or tax ID number of the billing dentist or dental entity. BILLING DENTIST OR DENTAL ENTITY (Leave blank if dentist or dental entity is not submitting claim on behalf of the patient or insured/subscriber.) 48 Name, Address, City, State, Zip Holliday, John H. 13 E Main Street Scottsdale, AZ 855 49 NPI 65431 5 Phone 50 License 987-65431 5a Additional 51 SSN or TIN 13-45-6789 5. Phone Not required 5a. Additional Required if Applicable 53. Signature of Treating Dentist Required The claim must be signed by the provider or his/her authorized representative. Rubber stamp signatures are acceptable if initialed by the provider representative. Enter the date on which the claim was signed. 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) 54 NPI 55 License 56 Address, City, State, Zip 56a Provider Specialty 5 Phone 5a Additional 49. NPI Required Enter the appropriate NPI of the billing dentist or dental entity 1
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) 54 NPI 78913 55 License 56 Address, City, State, Zip 56a Provider Specialty 5 Phone 5a Additional 50. License Required Enter the license number of the billing dentist or dental entity. 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) 54 NPI 78913 55 License 987-6531 56 Address, City, State, Zip 56a Provider Specialty 5 Phone 5a Additional 56. Address (Treating Dentist) Not required 56a. Specialty Not required 57. Phone (Treating Dentist) Not required 58. Additional Required if Applicable 13