At a glance

  • Depending on the plan and service, an office may be asked for radiographs, periodontal charting, narratives, photographs, prior treatment information, invoices, or an explanation of benefits from another plan.
  • Make sure attachments identify the correct patient and correspond to the procedures on the claim.
  • Send what is needed for the claim and applicable payer requirements.

Common attachment categories

Depending on the plan and service, an office may be asked for radiographs, periodontal charting, narratives, photographs, prior treatment information, invoices, or an explanation of benefits from another plan. The required set varies.

Label and match documents

Make sure attachments identify the correct patient and correspond to the procedures on the claim. If the office is sending paper, use a reliable internal method to keep multi-page records together and retain a copy.

Avoid unnecessary disclosure

Send what is needed for the claim and applicable payer requirements. A billing workflow should not encourage staff to include unrelated clinical information merely because it exists in the chart.

Dental-claim review

  • Send only the records or images the plan requests for the procedure and claim situation.
  • Label attachments so the payer can associate them with the correct patient and claim.
  • Keep a copy of what was sent and protect unnecessary PHI from disclosure.

Sources and verification

Use the ADA source below for the current 2024 Dental Claim Form and completion guidance, together with the dental plan’s requirements.

Related guides

Try the software

MedClaimSoftware’s ADA Dental Claim program is designed for the current 2024 form and can save/retrieve claim data and print from Windows. A limited-use trial is available without a credit card. ADA Dental Claim software.

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