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IT’S EASIER THAN YOU THINK! Information on the New ADA Claim Form
By Marianne Harper

Change – it strikes fear in most of us. According to President John F. Kennedy, "Change is the law of life. And those who look only to the past or present are certain to miss the future."1 The year 2007 has brought several changes for dental practices with regard to insurance processing that will help dental practices file claims more efficiently in the future. You are probably already aware of the ADA procedure code additions, deletions and revisions. However, you may not be aware of the changes to the dental claim form. The requirement for including NPI (National Provider Identifier) numbers on claim forms was the drive behind much of the changes to the ADA claim form. So fear not, we will address these changes to ease any concerns.

The front of the ADA claim form looks almost exactly the same as the prior ADA claim form and has the same data elements as the former except for fields to report NPI numbers for the treating dentist and the billing dentist. Fields 49 and 54 were formerly used to report Provider ID’s but they will now be used to report the NPI and are appropriately titled "NPI". Due to the fact that the treating dentist may not be the billing dentist, the ADA designated field 49 for the billing dentist’s NPI and field 54 for the treating dentist’s NPI.

Do you know whether you are required to have an NPI that is type I or type II, or both? The answer is not difficult. Practices that are unincorporated sole proprietorships are given type I NPI numbers while practices that have claim payments made to the organization, not the treating dentist, are given type II numbers. Type I NPI numbers are to be reported in field 54 while type II are placed in field 49. If your practice meets both criteria and you have two NPI’s or will receive two NPI’s, you will want to know which number to use. According to Patrick Cannady, the Coordinator of Dental Informatics at the ADA, "the NPI rule does not have any preference as to which type of NPI is used for this purpose; providers must enumerate and use their NPI’s according to their business needs and the information requirements of health plans".

There are other fields (52A and 58) on the ADA form that are titled "Additional Provider ID." These fields are not to be used for NPI, social security, or tax ID number reporting but are, instead, to be used for legacy identifiers. Legacy Identifiers (LID’s) are numbers created by entities such as third-party payers and the Federal government.

The old field 58 that had been used to report "Treating Provider Specialty" has been moved to the new field 56A. The following is a list of the ADA specialty codes to be used in field 56A but the ADA has indicated that the general code for "Dentist" may be used instead of the other codes.

Dentist
General Practice
Dental Specialty
122300000X
1223G0001X
  • Dental Public Health
  • Endodontics
  • Orthodontics
  • Pediatric Dentistry
  • Periodontics
  • Prosthodontics
  • Oral & Maxillofacial Pathology  
  • Oral & Maxillofacial Radiology
  • Oral & Maxillofacial Surgery
1223D0001X
1223E0200X
1223X0400X
1223P0221X
1223P0300X
1223P0700X
1223P0106X
1223D0008X
1223S0112X

Several other changes appear on the new ADA claim form. These changes simply involve new descriptions to the fields on the form that give more specific instructions but don’t change the required information.

Practices that still file claims on paper may have heard that they will not need to obtain an NPI. In principle, this is correct. However, some third party payers will require NPI’s. If your practice only files paper claims, you will need to check with the carriers to determine if you will need to obtain an NPI.

For additional information or to obtain updated information in regard to the ADA claim form or the CDT 2007/2008 procedure codes, please contact www.ada.org/goto/dentalcode. This site also contains a repository of "Questions and Answers" that can be quite helpful.

While many changes in life and business can be difficult, I believe that you can see that that does not apply to the ADA 2007/2008 claim form.

1"Wisdom Quotes: Quotations to Inspire and Change", Jone Johnson Lewis, Available at www.wisdomquotes.com. Accessed December 27, 2006

Author Biography

Marianne Harper, President
The Art of Practice Management
2217 Fox Horn Road
New Bern, NC 28562
252-637-6259 phone
252-637-0009 fax
a.p.m.1@suddenlink.net
www.artofpracticemanagement.com

Marianne Harper’s career in dentistry has spanned over twenty five years. She is a dental practice management consultant who is also a published author, a lecturer and a trainer. Her areas of specialty include front desk, dental-medical cross coding, accounts receivable controls, and employment law. She is a member of SCN (Speaking Consulting Network) and PMCA (Professional Management Consultants Association).

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