Dental Claim Form  
HEADER INFORmATION  
1. Type of Transaction (Mark all applicable boxes)  
Statement of Actual Services  
EPSDT / Title XIX  
Request for Predetermination/Preauthorization  
2. Predetermination/Preauthorization Number  
POlICyHOlDER/SUBSCRIBER INFORmATION (For Insurance Company Named in #3)  
12. Policyholder/Subscriber Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code  
INSURANCE COmPANy/DENTAl BENEFIT PlAN INFORmATION  
. Company/Plan Name, Address, City, State, Zip Code  
3
13. Date of Birth (MM/DD/CCYY)  
14. Gender  
M
15. Policyholder/Subscriber ID (SSN or ID#)  
F
OTHER COVERAgE (Mark applicable box and complete items 5-11. If none, leave blank.)  
16. Plan/Group Number  
17. Employer Name  
4
. Dental? (If both, complete 5-11 for dental only.)  
Medical?  
5. Name of Policyholder/Subscriber in #4 (Last, First, Middle Initial, Suffix)  
PATIENT INFORmATION  
1
8. Relationship to Policyholder/Subscriber in #12 Above  
19. Reserved For Future  
Use  
6
. Date of Birth (MM/DD/CCYY)  
. Plan/Group Number  
7. Gender  
M
8. Policyholder/Subscriber ID (SSN or ID#)  
Self Spouse Dependent Child  
Other  
F
20. Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code  
9
10. Patient’s Relationship to Person named in #5  
Self Spouse Dependent  
1. Other Insurance Company/Dental Benefit Plan Name, Address, City, State, Zip Code  
Other  
1
21. Date of Birth (MM/DD/CCYY)  
22. Gender  
M
23. Patient ID/Account # (Assigned by Dentist)  
F
RECORD OF SERVICES PROVIDED  
2
5. Area 26.  
2
4. Procedure Date  
27. Tooth Number(s)  
or Letter(s)  
28. Tooth  
Surface  
29. Procedure  
Code  
29a. Diag.  
Pointer  
29b.  
Qty.  
of Oral Tooth  
Cavity System  
30. Description  
31. Fee  
(MM/DD/CCYY)  
1
2
3
4
5
6
7
8
9
10  
3
3. Missing Teeth Information (Place an “X” on each missing tooth.)  
10 11 12 13 14 15 16  
31 30 29 28 27 26 25 24 23 22 21 20 19 18 17  
5. Remarks  
34. Diagnosis Code List Qualifier  
34a. Diagnosis Code(s)  
( ICD-9 = B; ICD-10 = AB )  
31a. Other  
Fee(s)  
1
2
3
4
5
6
7
8
9
_________________  
_________________  
A
C
D
3
2
(Primary diagnosis in “A”)  
_________________  
_________________ 32. Total Fee  
B
3
AUTHORIZATIONS  
ANCIllARy ClAIm/TREATmENT INFORmATION  
38. Place of Treatment  
3
6. I have been informed of the treatment plan and associated fees. I agree to be responsible for all  
charges for dental services and materials not paid by my dental benefit plan, unless prohibited by  
law, or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all  
or a portion of such charges. To the extent permitted by law, I consent to your use and disclosure  
of my protected health information to carry out payment activities in connection with this claim.  
(e.g. 11=office; 22=O/P Hospital)  
n
Use “Place of Service Codes for Professional Claims”)  
39. Enclosures (Y or N)  
(
40. Is Treatment for Orthodontics?  
41. Date Appliance Placed (MM/DD/CCYY)  
44. Date of Prior Placement (MM/DD/CCYY)  
No (Skip 41-42)  
Yes (Complete 41-42)  
X _____________________________________________________________________________  
Patient/Guardian Signature Date  
42. Months of Treatment  
Remaining  
43. Replacement of Prosthesis  
No  
Yes (Complete 44)  
37. I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly  
to the below named dentist or dental entity.  
45. Treatment Resulting from  
Occupational illness/injury  
Auto accident  
Other accident  
X _____________________________________________________________________________  
Subscriber Signature Date  
46. Date of Accident (MM/DD/CCYY)  
47. Auto Accident State  
BIllINg DENTIST OR DENTAl ENTITy (Leave blank if dentist or dental entity is not  
TREATINg DENTIST AND TREATmENT lOCATION INFORmATION  
submitting claim on behalf of the patient or insured/subscriber.)  
53. I hereby certify that the procedures as indicated by date are in progress (for procedures that require  
multiple visits) or have been completed.  
48. Name, Address, City, State, Zip Code  
X________________________________________________________________________________  
Signed (Treating Dentist)  
Date  
54. NPI  
55. License Number  
5
6a. Provider  
56. Address, City, State, Zip Code  
Specialty Code  
49. NPI  
50. License Number  
51. SSN or TIN  
52. Phone  
Number  
52a. Additional  
Provider ID  
57. Phone  
Number  
58. Additional  
Provider ID  
(
)
-
(
)
-
©
2012 American Dental Association  
To reorder call 800.947.4746  
or go online at adacatalog.org  
J430D (Same as ADA Dental Claim Form – J430, J431, J432, J433, J434)  
The following information highlights certain form completion instructions. Comprehensive ADA Dental Claim Form completion instructions  
are printed in the CDT manual. Any updates to these instructions will be posted on the ADA’s web site (ADA.org).  
GENERAL INSTRUCTIONS  
A. The form is designed so that the name and address (Item 3) of the third-party payer receiving the claim (insurance company/dental  
benefit plan) is visible in a standard #9 window envelope (window to the left). Please fold the form using the ‘tick-marks’ printed  
in the margin.  
B. Complete all items unless noted otherwise on the form or in the CDT manual’s instructions.  
C. Enter the full name of an individual or a full business name, address and zip code when a name and address field is required.  
D. All dates must include the four-digit year.  
E. If the number of procedures reported exceeds the number of lines available on one claim form, list the remaining procedures on  
a separate, fully completed claim form.  
COORDINATION OF BENEFITS (COB)  
When a claim is being submitted to the secondary payer, complete the entire form and attach the primary payer’s Explanation of Benefits  
(EOB) showing the amount paid by the primary payer. You may also note the primary carrier paid amount in the “Remarks” field (Item 35).  
There are additional detailed completion instructions in the CDT manual.  
DIAGNOSIS CODING  
The form supports reporting up to four diagnosis codes per dental procedure. This information is required when the diagnosis may affect  
claim adjudication when specific dental procedures may minimize the risks associated with the connection between the patient’s oral  
and systemic health conditions. Diagnosis codes are linked to procedures using the following fields:  
Item 29a – Diagnosis Code Pointer (“A” through “D” as applicable from Item 34a)  
Item 34 – Diagnosis Code List Qualifier (B for ICD-9-CM; AB for ICD-10-CM)  
Item 34a – Diagnosis Code(s) / A, B, C, D (up to four, with the primary adjacent to the letter “A”)  
PLACE OF TREATMENT  
Enter the 2-digit Place of Service Code for Professional Claims, a HIPAA standard maintained by the Centers for Medicare and Medicaid  
Services. Frequently used codes are:  
11 = Office; 12 = Home; 21 = Inpatient Hospital; 22 = Outpatient Hospital; 31 = Skilled Nursing Facility; 32 = Nursing Facility  
The full list is available online at “www.cms.gov/PhysicianFeeSched/Downloads/Website_POS_database.pdf”  
PROVIDER SPECIALTY  
This code is entered in Item 56a and indicates the type of dental professional who delivered the treatment. The general code listed as  
“Dentist” may be used instead of any of the other codes.  
Category / Description Code  
Code  
Dentist  
A dentist is a person qualified by a doctorate in dental surgery (D.D.S.)  
122300000X  
or dental medicine (D.M.D.) licensed by the state to practice dentistry,  
and practicing within the scope of that license.  
General Practice  
Dental Specialty (see following list)  
Dental Public Health  
1223G0001X  
Various  
1223D0001X  
1223E0200X  
1223X0400X  
1223P0221X  
1223P0300X  
1223P0700X  
1223P0106X  
1223D0008X  
1223S0112X  
Endodontics  
Orthodontics  
Pediatric Dentistry  
Periodontics  
Prosthodontics  
Oral & Maxillofacial Pathology  
Oral & Maxillofacial Radiology  
Oral & Maxillofacial Surgery  
Provider taxonomy codes listed above are a subset of the full code set that is posted at “www.wpc-edi.com/codes/taxonomy”