Fill out ADA Dental Claim Form online
The ADA Dental Claim Form is the standard form used by dental professionals to submit claims to dental insurance carriers for reimbursement of dental services. Published by the American Dental Association, it captures patient information, treating dentist details, diagnosis codes, CDT procedure codes, and fee information.
How to fill out ADA Dental Claim Form
Complete the header and insurance information
Enter the dental plan name, carrier address, and check whether this is a pre-treatment estimate or a claim for payment. Indicate if this is the primary or secondary insurance claim.
Enter patient and subscriber information
Fill in the subscriber's name, address, date of birth, plan/group number, and employer. If the patient is not the subscriber (e.g., a dependent), complete the patient information section separately.
Record the services performed
List each procedure with the date of service, tooth number or letter, surface(s), CDT procedure code, description, and fee. Include any applicable diagnosis codes.
Complete the dentist information and sign
Enter the treating dentist's name, NPI number, license number, address, and phone number. The dentist must sign and date the form to certify the accuracy of the information.
About ADA Dental Claim Form
Who needs this form
Dental providers, dental billing staff, and patients who need to submit claims to their dental insurance carrier for reimbursement of dental services.
Where to submit
Submit to the patient's dental insurance carrier (e.g., Delta Dental, Cigna, MetLife). The specific mailing address or electronic submission portal depends on the insurance company. Many practices submit electronically via dental practice management software.
Source and content freshness
- Filing deadlines may shift for weekends and holidays. Verify due dates with official instructions.
Common mistakes to avoid
- Using incorrect CDT procedure codes for the services rendered
- Missing or invalid tooth numbers or surfaces
- Not including the treating dentist NPI number
- Omitting required pre-authorization information for certain procedures