CSHCN 2008 > Dental > Claims Information

13.5.4 Dental Claim Paper Billing

All participating CSHCN Services Program dental providers must use the ADA Dental Claim Form (Copyright 2006, American Dental Association) for paper claim submissions to the CSHCN Services Program and can obtain copies of this form by contacting the ADA at 1-800-947-4746. Any paper dental claim submitted using any other version of the dental claim form is not processed and is returned to the submitter.

Claims must contain the billing provider's full name, address, and/or provider identifier. The billing provider's full name and address must be entered in Block 48 of the ADA Dental Claim Form, and the nine-digit provider identifier must be entered in Block 49. A claim without a provider name, address, or provider identifier cannot be processed.

Refer to: Chapter 5.7.1.9, "Instructions for Completing the ADA Dental Claim Form," on page 5-37.