ADA Claim Form
The standardised paper or electronic claim document, officially titled the ADA Dental Claim Form, used to submit dental treatment claims to insurers in the United States.
Full Definition
The ADA Dental Claim Form (currently the 2019 version) is the industry-standard document used by dental providers to request reimbursement from dental benefit plans. It captures patient demographics, subscriber information, treating provider details, tooth numbers, procedure codes (CDT), and diagnosis codes. Editors reviewing completed claim forms must verify that all required fields are populated, tooth numbers correspond to documented treatment, and procedure descriptions match the CDT codes used. The form's structure is specified by the ADA and aligned with ANSI X12 837D electronic transaction standards. Incomplete or inconsistent claim forms are a leading cause of claim delay and denial.
Usage
Usage note: Refer to this document as the 'ADA Dental Claim Form' on first reference in formal documents. Note the version year (e.g., 2019) when version-specific instructions are relevant.
In Context
- "The biller completed the ADA Dental Claim Form, entering the CDT code and corresponding tooth number in boxes 24 and 26." — Insurance billing workflow document
- "Editors should confirm that the treating provider's NPI matches the number on file with the carrier before approving the ADA Claim Form for submission." — Claims audit checklist