ADA dental claims

Here's how to bill using a paper American Dental Association (ADA) J400 dental claim form. Hand-written or faxed claims will not be accepted.

Block number Field name Instructions
1 Type of transaction Indicate whether the claim form is being used for pre-treatment approval or for actual services provided
2 Predetermination/Preauthorization number (optional) Enter predetermination/preauthorization number
3 Carrier name and address The name and current address of the insurance carrier where the claim is being sent
4 Other dental or medical insurance? Check yes or no to indicate whether patient is covered by another health or dental plan. Data in this field is used to determine if HPHC is the primary or secondary payer.
  • If yes, complete 5–11
  • If no, skip 5–11
5 Name of policyholder/subscriber Enter the policyholder/subscriber's last name, first name and middle initial, if any, as shown on the policyholder/subscriber's HPHC ID card. Include any titles or both names, if hyphenated.
6 Date of birth Enter the policyholder/subscriber’s date of birth (MMDDYYYY); important for verification of eligibility
7 Gender Enter gender of policyholder/subscriber
8 Policy/subscriber ID Enter the policyholder/subscriber's ID number from the other insurance carrier
9 Plan/group number Enter the plan/group number of the policyholder/subscriber 
10 Relationship to policyholder/subscriber Enter relationship of patient to insured (self, spouse, child, etc.). Policyholder/subscriber refers to insured person.
11 Other insurance name and address The name and address of the other insurance
12 Policyholder/subscriber's name and address Used for identification purposes only (helpful if last names differ). Enter the policyholder/subscriber's address and telephone number, except when the address is the same as the patient's; then enter the word "same."
13 Date of birth Enter the policyholder/subscriber's date of birth (MMDDYYYY). Important for verification of eligibility.
14 Gender Enter gender of policyholder/subscriber
15 Policyholder/subscriber ID Enter the 11-character member ID number, including the two-digit suffix (contract number), as shown on the policyholder/subscriber's ID card
16 Plan/group number Enter the plan/group number of the policyholder/subscriber
17 Employer name Enter the insured's employer name
18 Relationship to policyholder/subscriber Enter relationship of patient to insured (self, spouse, child, etc.). Policyholder/subscriber refers to insured person.
19 Student status (optional) Check FTS (full time student) or PTS (part time student)
20 Patient's name and address The patient's name and address, used for identification purposes only (helpful if last names differ). Enter the patient's address and telephone number
21 Date of birth Enter the patient's date of birth (MMDDYYYY), important for verification of eligibility
22 Gender Enter gender of patient
23 Patient ID/account # Enter the patient ID/account # assigned by dentist
24 Procedure date Enter the procedure date
25 Area of oral cavity (optional) Enter the area of oral cavity
26 Tooth system Enter the tooth system
27 Tooth number(s) or letter(s) Enter the tooth number(s) or letter(s)
28 Tooth surface Enter the tooth surface
29 Procedure code Enter the appropriate ADA or CPT procedure code
30 Description Enter the description for service rendered
31 Fee Enter the service line charge for the service rendered
32 Other fee(s) Enter other fee(s) for the services rendered
33 Total fee Enter total charges for the services rendered
34 Missing tooth (optional) Mark missing teeth on diagram
35 Remarks Indicate other information that may be helpful in determining benefits. HPHC requires a diagnosis code (including routine—V722)
36 Patient/guardian signature Have the patient or authorized representative sign and date this block unless the signature is on file
37 Subscriber signature Have the subscriber sign and date this block unless the signature is on file
38 Place of treatment Enter place where treatment was rendered to patient
39 Number of enclosures (optional) Enter number of radiograph(s), oral images(s) or models(s)
40 Is treatment for orthodontics? Check yes or no
  • If yes, complete 41–42
  • If no, skip 41–42
41 Date appliance placed Enter date appliance placed
42 Months of treatment remaining Enter months of treatment remaining
43 Replacement of prosthesis? Most dental contracts have specific limitations on replacements. Check yes or no. If yes, complete 44. Data important to determine eligibility and liability.
44 Date prior placement Enter date of prior placement
45 Treatment resulting from Check off either occupational illness/injury, auto accident or other accident.
46 Date of accident Enter date of accident
47 Auto accident state Enter auto accident state
48 Billing dentist name and address Enter the name and provider number of the individual dentist or the group practice responsible for billing. This is the name that should appear on any payments to the dental provider, and this address is used to return any rejected claims.
49 NPI Enter the dentist's National Provider Identifier (NPI number) 
50 License number Enter the state license number of the dental provider.
51 SSN or TIN Enter dentist's federal tax ID (employer ID number) or Social Security number
52 Phone number Enter the phone number of the dental provider
52A Additional provider ID (optional)
 
53 Treating dentist signature Have the treating dentist sign and date this block
54 NPI Enter the dentist's National Provider Identifier (NPI number) if different than box 49
55 License number Enter the state license number of the dental provider
56 Treating dentist address Enter the address of the individual dentist or the group practice. This address is used by HPHC to return any rejected claims.
56A Provider specialty code Enter the provider specialty code
57 Phone number Enter the phone number of the dental provider
58 Additional provider ID (optional)