ADA 2012 Claim Form
Posted 5/31/13; Modified 10/23/13
The American Dental Association (ADA) revised their dental claim form effective July 1, 2012. The form was updated primarily to allow dentists to include a diagnosis code when a specific diagnosis may have an impact on the adjudication of the claim. This revision replaces the previous ADA 2006 Dental Claim Form.
Comprehensive ADA Dental Claim Form Completion Instructions, a sample form, and details of changes included in the new form can be accessed via the website: www.ada.org.
HealthChoice, Department of Corrections, and Department of Rehabilitation Services will accept both the previous ADA 2006 Dental Claim Form and the revised 2012 ADA Dental Claim Form through December 31, 2013. Beginning January 1, 2014, only the 2012 ADA Dental Claim Form will be accepted.
If you have any questions, please contact the dental claims administrator at 1-405-416-1800 or toll-free 1-800-782-5218.