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December 2016 Texas Medicaid Provider Procedures Manual

Section 6: Claims Filing : 6.7 2012 American Dental Association (ADA) Dental Claim Filing Instructions : 6.7.4 2012 ADA Dental Claim Form Instruction Table

The following table is an itemized description of the questions appearing on the form. Thoroughly complete the 2012 ADA Dental claim form according to the instructions in the table to facilitate prompt and accurate reimbursement and reduce follow-up inquiries.
For Texas Medicaid, check the Statement of Actual Services Box. The other two boxes are not applicable. Do not use the 2012 ADA Dental Claim Form as a Texas Medicaid Prior Authorization form.
Predetermination/ Preauthorization Number
Company/Plan Name, Address, City, State, ZIP Code
Check No if no other dental or medical coverage (skip Blocks 5-11). Check Yes if dental or medical coverage is available other than Texas Medicaid coverage, and complete Blocks 5‑11.
Other Coverage Information
Enter the information for the policyholder or subscriber, not necessarily the patient. May be a parent or legal guardian of the patient receiving treatment.
Name of Policyholder/Subscriber in # 4
Date of Birth (MM/DD/CCYY)
Policyholder/Subscriber ID
Patient’s Relationship to Person Named in # 5
Other Insurance Company/Dental Benefit Plan Name, Address, City, State, ZIP Code
Policyholder/Subscriber Name (Last, First, Middle Initial, Suffix), Address, City, State, ZIP Code
Enter the Medicaid patient’s last name, first name, and middle initial as printed on the Medicaid identification form.
Date of Birth (MM/DD/CCYY)
Policyholder/Subscriber ID
Relationship to Policyholder/ Subscriber in # 12 Above
Name (Last, First, Middle Initial, Suffix), Address, City, State, ZIP Code
Date of Birth (MM/DD/CCYY)
Patient ID/Account # (Assigned by Dentist)
Optional: Enter the patient identification number if it is different than the subscriber/insured’s identification number.
Procedure Date (MM/DD/CCYY)
Enter the letter(s) from Box 34 that identified the diagnosis code(s)applicable to the dental procedure. List the primary diagnosis pointer first.
identified in Item 29 is delivered to the patient on the date of service shown in item 24. The default value is “01”.
Provide a brief description of the service provided (e.g., abbreviation of the procedure code’s nomenclature). Field length reduced by 8 characters to provide space for added items 29a and 29b.
Enter usual and customary charges for each service listed. Charges must not be higher than the fees charged to private pay clients.
When other changes applicable to dental services provided must be reported, enter the amount here. Charges may include state tax and other charges imposed by regulatory bodies. Identify the source of each payment date in Block 11.
claims, enter “continue” on initial and subsequent claim forms. Indicate the total of all charges on the last claim.
Note: Indicate the page number of the attachment (for example, page 2 of 3) in the top right-hand corner of the form.
Missing Teeth Information
Report missing teeth when pertinent to periodontal, prosthodontic (fixed and removable), or implant services procedures on a particular claim.
Enter up to four applicable diagnosis codes after each letter (A-D). The primary diagnosis code is entered adjacent to the letter “A”.
The facility name and address and NPI if the place of treatment indicated in Block 38 is not the provider’s office.
To provide more information such as reports for local orthodontia codes, 999 codes, multiple supernumerary teeth, or remarks.
Enter the 2-digit place of service (POS) code for professional claims, which is a Health Insurance Portability and Accountability Act (HIPAA) standard.
Enter a “Y” or “N” to indicate whether or not there are enclosures of any type included with the claim submission (e.g., radiographs, oral images, models).
Is Treatment for Orthodontics?
Replacement of Prosthesis?
Treatment Resulting from (Check applicable box)
Providers are required to check the Other Accident box for emergency claim reimbursement. If the Other Accident box is checked, information about the emergency must be provided in Block 35.
Date of Accident (MM/DD/CCYY)
Name, Address, City, State, ZIP Code
Enter the name and address of the billing group or individual provider. Do not enter the name and address of a provider employed within a group.
Enter the billing provider’s NPI for a group or an individual. Do not enter the NPI for a provider employed within a group.
Social Security Number (SSN) or Tax Identification Number (TIN)
Enter the area code and number for the billing group or individual Do not enter the telephone number of a provider employed within a group.
Enter the nine-digit TPI assigned to the billing dentist or dental entity. Do not enter the TPI for a provider employed within a group.
Billing services may print “Signature on File” in place of the provider’s signature if the billing service obtains and retains on file a letter signed by the provider authorizing this practice.
Required: Enter the TPI for the dentist’s enrolled as part of a group who treated the patient.

Texas Medicaid & Healthcare Partnership
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