糖心logoDental Claim Form

The 糖心logoDental Claim Form provides a common format for reporting dental services to a patient's dental benefit plan. 糖心logopolicy promotes use and acceptance of the most current version of the 糖心logoDental Claim Form by dentists and payers.

The following materials are prepared by 糖心logoPractice Institute staff with contributions from the 糖心logoCouncil on Dental Benefit Programs and other internal and external knowledge experts.

糖心logoSample Dental Claim Form and Completion Instructions

Download the current version of the 2024 糖心logoDental Claim Form © (PDF)
Download the Comprehensive 糖心logoDental Claim Form Completion Instructions (PDF) for all items (#’s 1 through 58)
Special Completion Instructions – Reporting Ordering, Referring, and Prescribing Providers (PDF)
Download the Special Completion Instructions for Medicare Administrative Modifiers © (PDF)

Completion Instructions Supplement 1 鈥� Reporting Oral Cavity, Tooth Numbers or Tooth Surfaces

This "糖心logoGuide to Dental Procedures Reported with Area of the Oral Cavity or Tooth Anatomy (or Both)" Completion Instructions Supplement 1 concerns claim form item #s 25, 27, and 28. It specifies, by CDT code, when Area of the Oral Cavity, Tooth Numbers or Tooth Surfaces should be reported.

Completion Instructions Supplement 2 鈥� Guide to Reporting D9985

These instructions concern claim form items # 24 through 32 and are applicable only when reporting procedure code 鈥淒9985 sales tax.鈥�

Special Completion Instructions for D9985

Completion Instructions Supplement 3 鈥� Universal Tooth Designation System ValueSet

The universal tooth designation or numbering system is accepted and approved by the 糖心logoand is the most commonly used system used by dental professionals in America. This valueset includes the codes which should be used on the 糖心logoDental Claim Form as defined in the Completion Instructions. The associated International Organization for Standardization (ISO) designation system for teeth (ISO/3950) is included to assist with mapping and should not be used on the 糖心logoClaim Form.

Universal Tooth Designation System ValueSet

Technical questions concerning the 糖心logoDental Claim Form's content or completion should be directed to the ADA's Practice Institute staff via email (dentalcode@ada.org). You can also reach out to us from 8:00 a.m. to 5 p.m. Central time, Monday through Friday by phone 800.621.8099. The 糖心logoDental Claim Form and the CDT manual are copyrighted documents. Reproduction of copyrighted information is subject to a licensing agreement.

For information about licensing of the 糖心logoDental Claim Form, please see CDT.
For any questions regarding pricing or purchasing copies of the 糖心logoDental Claim Form, including one that may be individually completed or printed. please visit the or call 800.947.4746.