ADA Dental Claim Form Completion Instructions

Version 2019 © American Dental Association

Page 1 of 16

Completion Instructions Date: 2022Feb11

Introduction

The ADA’s Council on Dental Benefit Programs has responsibility for electronic and paper dental claim

content and completion instructions. Staff from the Center for Dental Benefits, Coding and Quality

within the ADA’s Practice Institute maintain the paper ADA Dental Claim Form and its completion

instructions. According to ADA policy the paper form’s data content must be in harmony with the

HIPAA standard electronic dental claim transaction.

The ADA Dental Claim Form was last structurally revised in 2012 to incorporate key data content

changes that enables diagnosis code reporting that was also incorporated into the now current version

of the HIPAA standard (837D v5010) electronic dental claim. This version of the ADA form incorporates

editorial changes to further its consistency with the 837D.

Summary of Form Version 2019 Editorial and Completion Instruction Changes

Change Description

Affected Form

# Field Name

Consistent completion instruction captions for these fields.

Policyholder/Subscriber

Identifier

Changed from two check boxes, one for Male (M) and another for

Female (F), to three with the third being a box for Unknown (U).

Gender

Addition of NOTE that points to other online guidance on when

this information is reported.

25 Area of Oral Cavity

Consistent instructions for reporting procedures involving multiple

teeth

27 Tooth Numbers or Letters

Addition of NOTE to clarify that tooth numbers are based on

morphology, not anatomic location.

Tooth Numbers or Letters

Missing Teeth

Remarks

Removal of coding option “B” as it applies to an ICD-10-CM

version that is no longer valid for use.

34 Diagnosis Code List Qualifier

Addition of clarifying NOTE that: a) addresses when this

information would be reported; and b) refers to other online

guidance for completion when this information is reported.

34a

Diagnosis Code List Qualifier

Diagnosis Code(s)

Additional information concerning completion when teledentistry

procedure code is reported.

Place of Service Code

Treatment Location Address

The current version of the paper form (2019 © American Dental Association), front and reverse sides, is

illustrated on the

next two pages. The illustrations are then followed by comprehensive form completion

instructions.

ADA Dental Claim Form Completion Instructions

Version 2019 © American Dental Association

Page 2 of 16

Completion Instructions Date: 2022Feb11

ADA Dental Claim Form Completion Instructions

Version 2019 © American Dental Association

Page 3 of 16

Completion Instructions Date: 2022Feb11

ADA Dental Claim Form Completion Instructions

Version 2019 © American Dental Association

Page 4 of 16

Completion Instructions Date: 2022Feb11

DATA ELEMENT SPECIFIC INSTRUCTIONS

Form completion instructions are provided for each data item, which is indicated by a number. Please

note that data items are in groups of related information. These instructions explain the reasons for

such groupings, and the relationships (if any) between groups.

Header Information

The ‘header’ provides information about the type of submission being made. This information applies

to the entire transaction.

Type of Transaction: There are three boxes that may apply to this submission. If services have

been performed, mark the “Statement of Actual Services” box. If there are no dates of service,

mark the box marked “Request for Predetermination / Preauthorization”. If the claim is through

the Early and Periodic Screening, Diagnosis and Treatment Program, mark the box marked

‘EPSDT/Title XIX’.

Predetermination/Preauthorization Number: If you are submitting a claim for a procedure that has

been pre-authorized by a third party payer, enter the preauthorization or predetermination number

provided by the insurance company.

Insurance Company/Dental Benefit Plan Information

Company/Plan Name, Address, City, State, Zip Code: This Item is always completed. Enter the

information for the insurance company or dental benefit plan that is the third party payer receiving

the claim.

•

If the patient is covered by more than one plan, enter the primary insurance company

information here for the initial claim submission.

•

When submitting a separate claim to the secondary carrier, place the secondary carrier’s

company/plan name and address information here.

ADA Dental Claim Form Completion Instructions

Version 2019 © American Dental Association

Page 5 of 16

Completion Instructions Date: 2022Feb11

Other Coverage

This area of the claim form provides information on the existence of additional dental or medical

insurance policies. This is necessary to determine if multiple coverages are in effect, and the possibility of

coordination of benefits.

•

When the claim form is being prepared for submission to the primary carrier the information in

“Other Coverage” applies to the secondary carrier.

•

When the claim form is being prepared for submission to the secondary carrier the information in

“Other Coverage” applies to the primary carrier.

Other Dental or Medical Coverage?: Mark the box after “Dental?” or “Medical?” whenever a

patient has coverage under any other dental or medical plan, without regard to whether the

dentist or the patient will be submitting a claim to collect benefits under the other coverage.

• Leave blank when the dentist is not aware of any other coverage(s).

• When either box is marked, complete Items 5 through 11 in the “Other Coverage” section

for the applicable benefit plan.

• If both Dental and Medical are marked, enter information about the dental benefit plan in

Items 5 through 11.

Name of Policyholder/Subscriber with Other Coverage Indicated in #4 (Last, First, Middle Initial,

Suffix): If the patient has other coverage through a spouse, domestic partner or, if a child, through

both parents, the name of the person who has the other coverage is reported here.

Date of Birth (MM/DD/CCYY): Enter the date of birth of the person listed in Item #5. The date

must be entered with two digits each for the month and day, and four digits for the year of birth.

Gender: Mark the gender of the person who is listed in Item #5. Mark “M” for Male, “F” for

Female, or “U” for Unknown as applicable.

Policyholder/Subscriber Identifier (Assigned by Plan): Enter the unique identifying number

assigned by the third-party payer (e.g., insurance company) to the person named in Item #5,

which is on their identification card.

ADA Dental Claim Form Completion Instructions

Version 2019 © American Dental Association

Page 6 of 16

Completion Instructions Date: 2022Feb11

Plan/Group Number: Enter the group plan or policy number of the person identified in Item #5.

10.

Patient’s Relationship to Person Named in Item #5: Mark the patient’s relationship to the other

insured named in Item #5.

11.

Other Insurance Company/Dental Benefit Plan Name, Address, City, State, Zip Code: Enter the

complete information of the additional payer, benefit plan or entity for the insured named in Item

#5.

Policyholder/Subscriber Information (For Insurance Company Named in Item #3)

This section documents information about the insured person who may or may not be the patient.

•

When the claim form is being prepared for submission to the primary carrier the information

supplied applies to the person insured by the primary carrier.

•

When the claim form is being prepared for submission to the secondary carrier the information

entered applies to the person insured by secondary carrier.

12.

Policyholder/Subscriber Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code:

Enter the complete name, address and zip code of the policyholder/subscriber with coverage

from the company/plan named in #3.

13.

Date of Birth (MM/DD/CCYY): A total of eight digits are required in this field; two for the month,

two for the day of the month, and four for the year.

14.

Gender: This applies to the primary insured, who may or may not be the patient. Mark “M” for

Male, “F” for Female, or “U” for Unknown as applicable.

15.

Policyholder/Subscriber Identifier (Assigned by Plan): Enter the unique identifying number

assigned by the third-party payer (e.g., insurance company) to the person named in Item #12,

which is on their identification card.

16.

Plan/Group Number: Enter the policyholder/subscriber’s group plan/policy number.

17.

Employer Name: If applicable, enter the name of the policyholder/subscriber’s employer.

ADA Dental Claim Form Completion Instructions

Version 2019 © American Dental Association

Page 7 of 16

Completion Instructions Date: 2022Feb11

Patient Information

The information in this section of the claim form pertains to the patient.

18.

Relationship to Policyholder/Subscriber in #12 Above: Mark the relationship of the patient to the

person identified in Item #12 who has the primary insurance coverage. The relationship between

the insured and the patient may affect the patient’s eligibility or benefits available. If the patient

is also the primary insured, mark the box titled ‘Self’ and skip to item #23.

19.

Reserved For Future Use: Leave blank and skip to Item #20. (#19 was previously used to report

“Student Status.”)

20.

Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code: Enter the complete name,

address and zip code of the patient.

21.

Date of Birth (MM/DD/CCYY): A total of eight digits are required in this field; two for the month,

two for the day of the month, and four for the year of birth of the patient.

22.

Gender: This applies to the patient. Mark “M” for Male, “F” for Female, or “U” for Unknown as

applicable.

23.

Patient ID/Account # (Assigned by Dentist): Enter if the dentist’s office has assigned a number to

identify the patient. This is not required to process claim.

ADA Dental Claim Form Completion Instructions

Version 2019 © American Dental Association

Page 8 of 16

Completion Instructions Date: 2022Feb11

Record Of Services Provided

This section contains information regarding the proposed treatment (predetermination/preauthorization),

or treatment performed (actual services).

NOTE: Items 24 through 31, following, apply to each of the 10 available lines on the claim form for

reporting dental procedures provided to the patient. The remaining Items in this section of the form

(33-35) do not repeat.

24.

Procedure Date (MM/DD/CCYY): Enter procedure date for actual services performed or leave

blank if the claim is for preauthorization/predetermination. The date, if included, must have two

digits for the month, two for the day, and four for the year.

The presence or absence of a Procedure Date should be consistent with the type of

transaction(s) marked in Item #1 (e.g., actual services; predetermination / preauthorization).

25.

Area of Oral Cavity: Use of this field is conditional. Always report the area of the oral cavity

when the procedure reported in Item #29 (Procedure Code) refers to a quadrant or arch and the

area of the oral cavity is not uniquely defined by the procedure’s nomenclature. For example:

Report the applicable area of the oral cavity when the procedure code nomenclature includes

a general reference to an arch or quadrant, such as D4263 bone replacement graft – first

site in quadrant

Do not report the applicable area of the oral cavity when the procedure either: 1) incorporates

a specific area of the oral cavity in its nomenclature, such as D5110 complete denture –

maxillary; or 2) does not relate to any portion of the oral cavity, such as D9222 deep

sedation/general anesthesia – first 15 minutes.

NOTE: Detailed guidance on reporting Area of the Oral Cavity, Tooth Numbers and

Tooth Surfaces by CDT code is posted on the ADA Dental Claim Form web

page –

ADA Dental Claim Form

ADA Dental Claim Form Completion Instructions

Version 2019 © American Dental Association

Page 9 of 16

Completion Instructions Date: 2022Feb11

Area of the oral cavity is designated by a two-digit code, selected from the following code list:

Code Area

00 entire oral cavity

01 maxillary arch

02 mandibular arch

10 upper right quadrant

20 upper left quadrant

30 lower left quadrant

40 lower right quadrant

26.

Tooth System: Enter “JP” to indicate that teeth are being designated using the ADA’s

Universal/National Tooth Designation System (1-32 for permanent dentition and A-T for primary

dentition).

27.

Tooth Number(s) or Letter(s): Enter the appropriate tooth number or letter when the

procedure directly involves a tooth or range of teeth. Otherwise, leave blank.

NOTE: Numbers or letters reported are based on tooth morphology, not anatomic

position. This is the traditional and important concept to understand for

accurate documentation and reporting. For instance, a tooth may migrate

into an edentulous space, but that movement does not change its

morphology. Similarly, placement of an implant body need not be in an

anatomic tooth position, but the prosthesis placed is the morphological

equivalent of a missing tooth or range of teeth.

If the same procedure is performed on more than a single tooth on the same date of service there

are two options for reporting –

• Report each procedure, the tooth involved, and the fee on separate service lines

• Report the procedure on a single service line with the teeth involved in #27, the number

of times the procedure was delivered in the #29b (Quantity), and the total fee for all in

#31 (Fee)

When a procedure involves a range of teeth, the range is reported in this field. This is done either

with a hyphen “-” to separate the first and last tooth in the range (e.g., 1-4; 7-10; 22-27), or by the

use of commas to separate individual tooth numbers or ranges (e.g., 1, 2, 4, 7-10; 3-5, 22-27).

Supernumerary teeth in the permanent dentition are identified in the ADA’s Universal/National

Tooth Designation System (“JP”) by the numbers 51 through 82, beginning with the area of the

upper right third molar, following around the upper arch and continuing on the lower arch to the

area of the lower right third molar (for example, supernumerary number 51 is adjacent to the

upper right molar number 1; supernumerary number 82 is adjacent to the lower right third molar

number 32). This enumeration is illustrated in the following chart:

Upper Arch (commencing in the upper right quadrant and rotating counterclockwise)

Tooth # 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

‘Super’ # 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66

ADA Dental Claim Form Completion Instructions

Version 2019 © American Dental Association

Page 10 of 16

Completion Instructions Date: 2022Feb11

Lower Arch

Tooth # 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

‘Super’ # 82 81 80 79 78 77 76 75 74 73 72 71 70 69 68 67

Supernumerary teeth in the primary dentition are identified by the placement of the letter "S"

following the letter identifying the adjacent primary tooth (for example, supernumerary "AS" is

adjacent to "A"; supernumerary "TS" is adjacent to "T"). This enumeration is illustrated in the

following chart:

Upper Arch (commencing in the upper right quadrant and rotating counterclockwise)

Tooth # A B C D E F G H I J

‘Super’#

AS BS CS DS ES FS GS HS IS JS

Lower Arch

Tooth “#”

T S R Q P O N M L K

Super “#”

TS SS RS QS PS OS NS MS LS KS

28.

Tooth Surface: This Item is necessary when the procedure performed by tooth involves one or

more tooth surfaces. Otherwise leave blank. The following single letter codes are used to identify

surfaces:

Surface Code

Buccal B

Distal D

Facial (or labial) F

Incisal I

Lingual L

Mesial M

Occlusal O

Do not leave any spaces between surface designations in multiple surface restorations (e.g.,

MOD).

29.

Procedure Code: Enter the appropriate procedure code found in the version of the Code

on Dental Procedures and Nomenclature in effect on the “Procedure Date” (Item #24).

NOTE: Additional guidance concerning reporting select CDT codes (e.g.,

Teledentistry; Sales Tax) are in Coding Education and the ADA Claim Form

content linked to the CDT Code Portal web page –

www.ada.org/cdt

29a Diagnosis Code Pointer: Enter the letter(s) from Item 34 that identify the diagnosis code(s)

ADA Dental Claim Form Completion Instructions

Version 2019 © American Dental Association

Page 11 of 16

Completion Instructions Date: 2022Feb11

applicable to the dental procedure. List the primary diagnosis pointer first.

29b Quantity: Enter the number of times (01-99) the procedure identified in Item 29 is delivered to the

patient on the date of service shown in Item 24. The default value is “01.”

30.

Description: Provide a brief description of the service provided (e.g., abbreviation of the

procedure code’s nomenclature).

31.

Fee: Report the dentist’s full fee for the procedure. Resolution 44-2009 Statement on Reporting

Fees on Dental Claims adopted by the ADA House of Delegates, as follows, provides guidance

on the appropriate entry for this item.

Statement on Reporting Fees on Dental Claims

A full fee is the fee for a service that is set by the dentist, which reflects the costs of

providing the procedure and the value of the dentist’s professional judgment.

A contractual relationship does not change the dentist’s full fee.

It is always appropriate to report the full fee for each service reported to a third-party

payer.

(Note: Item 31 above is the last of the repeating ‘service line’ items.)

31a Other Fee(s): When other charges applicable to dental services provided must be reported, enter

the amount here. Charges may include state tax and other charges imposed by regulatory

bodies.

32.

Total Fee: The sum of all fees from lines in Item #31, plus any fee(s) entered in Item #31a

33.

Missing Teeth Information: Mark an “X” on the number of the missing tooth – for identifying

missing permanent dentition only. Report missing teeth when pertinent to Periodontal,

Prosthodontic (fixed and removable), or Implant Services procedures on a particular claim

NOTE: Numbers marked are based on tooth morphology, not anatomic position.

34.

Diagnosis Code List Qualifier: Enter the appropriate code to identify the diagnosis code source:

AB = ICD-10-CM

34a Diagnosis Code(s): Enter up to four applicable diagnosis codes after each letter (A. – D.). The

primary diagnosis code is entered adjacent to the letter “A.”

NOTE: #34 and #34a are required when a) the diagnosis may have an impact on the

adjudication of the claim in cases where specific dental procedures may

minimize the risks associated with the connection between the patient’s oral

and systemic health conditions; or b) when required by state regulation (e.g.,

Medicaid) or third-party payer contract provisions.

Detailed guidance on reporting ICD-10-CM diagnosis codes is posted on the

ADA Dental Claim Form web page –

ICD Reporting on ADA Dental Claim Form

35.

Remarks: This space may be used to convey additional information for a procedure code that

requires a report, or for multiple supernumerary teeth. It can also be used to convey additional

information you believe is necessary for the payer to process the claim (e.g., for a secondary

claim, the amount the primary carrier paid).

Remarks should be concise and pertinent to the claim submission. Claimants should note that an

entry in “Remarks” may prompt review by a person as part of claim adjudication, which may affect

ADA Dental Claim Form Completion Instructions

Version 2019 © American Dental Association

Page 12 of 16

Completion Instructions Date: 2022Feb11

overall time required to process the claim.

NOTE: When the claim is for a multi-unit implant supported prosthesis the supporting

implant body locations may not correlate to the anatomic location of a natural

tooth. An appropriate notation in “Remarks” may avoid a misunderstanding

when the claim is submitted to a third-party payer.

Authorizations

This section provides consent for treatment as well as permission for the payer to send any patient

benefit available for procedures performed directly to the dentist or the dental business entity.

36.

Patient Consent: The patient is defined as an individual who has established a professional

relationship with the dentist for the delivery of dental health care. For matters relating to

communication of information and consent, the term includes the patient’s parent, caretaker,

guardian, or other individual as appropriate under state law and the circumstances of the case.

By signing (or “Signature on File” notice) in this location of the claim form, the patient or patient’s

representative has agreed that he/she has been informed of the treatment plan, the costs of

treatment and the release of any information necessary to carry out payment activities related to

the claim.

Claim forms prepared by the dentist’s practice management software may insert “Signature on

File” when applicable in this Item.

37.

Authorize Direct Payment: The signature and date (or “Signature on File” notice) are required

when the Policyholder/Subscriber named in Item #12 wishes to have benefits paid directly to the

dentist/provider. This is an authorization of payment. It does not create a contractual relationship

between the dentist or dental entity and the insurance company.

Claim forms prepared by the dentist’s practice management software may insert “Signature on

File” when applicable in this Item.

ADA Dental Claim Form Completion Instructions

Page 13 of 16

Completion Instructions Date: 2022Feb11

Ancillary Claim/Treatment Information

This section of the claim form provides additional information to the third party payer regarding the claim.

38. Place of Treatment: Enter the 2-digit Place of Service Code for Professional Claims, a

HIPAA standard. Frequently used codes are:

11 = Office; 12 = Home; 21 = Inpatient Hospital; 22 = Outpatient Hospital; 31 =

Skilled Nursing Facility; 32 = Nursing Facility; 02 = Telehealth (aka Teledentistry)

All current codes are available online from the Centers for Medicare and Medicaid Services in

PDF format for download –

CMS Place of Service Code Set

39. Number of Enclosures (00 to 99): Enter a “Y” or “N” to indicate whether or not there are

enclosures of any type included with the claim submission (e.g., radiographs, oral

images, models)

40.

Is Treatment for Orthodontics?: If no, skip to Item #43. If yes, answer Items 41 & 42.

41.

Date Appliance Placed (MM/DD/CCYY): Indicate the date an orthodontic appliance was placed.

This information should also be reported in this section for subsequent orthodontic visits.

42.

Months of Treatment: Enter the total number of months required to complete the orthodontic

treatment, from the beginning to the end of the treatment plan.

43.

Replacement of Prosthesis?: This Item applies to Crowns and all Fixed or Removable Prostheses

(e.g., bridges and dentures).

Please review the following three situations in order to determine how to complete this Item.

If the claim does not involve a prosthetic restoration mark “NO” and proceed to Item

45.

If the claim is for the initial placement of a crown, or a fixed or removable prosthesis,

mark “NO” and proceed to Item 45.

If the patient has previously had these teeth replaced by a crown, or a fixed or

removable prosthesis, or the claim is to replace an existing crown, mark the “YES”

field and complete section 44.

ADA Dental Claim Form Completion Instructions

Page 14 of 16

Completion Instructions Date: 2022Feb11

44.

Date of Prior Placement (MM/DD/CCYY): Complete if the answer to Item #43 was “YES.”

45.

Treatment Resulting From: If the dental treatment listed on the claim was provided as a result of

an accident or injury, mark the appropriate box in this item, and proceed to Items #46 and #47. If

the services you are providing are not the result of an accident, this Item does not apply;

skip to Item #48.

46.

Date of Accident (MM/DD/CCYY): Enter the date on which the accident noted in Item #45

occurred. Otherwise, leave blank.

47.

Auto Accident State: Enter the state in which the auto accident noted in Item #45 occurred.

Otherwise, leave blank.

Billing Dentist Or Dental Entity

The ‘Billing Dentist’ or ‘Dental Entity’ section provides information on the individual dentist’s name, the

name of the practitioner providing care within the scope of their state licensure, or the name of the group

practice/corporation that is responsible for billing and other pertinent information. Depending on the

business relationship of the practice and the treating dentist, the information provided in this section may

not be the treating dentist. If the patient is submitting the claim directly, do not complete Items 48-

52a.

48.

Name, Address, City, State, Zip Code: Enter the name and complete address of a dentist or the

dental entity (corporation, group, etc.).

49.

NPI (National Provider Identifier): Enter the appropriate NPI type for the billing entity. A Type 2

NPI is entered when the claim is being submitted by an incorporated individual, group practice or

similar legally recognized entity. Unincorporated practices may enter the individual practitioners

Type 1 NPI.

NOTE: The NPI is an identifier assigned by the Federal government to all providers

considered to be HIPAA covered entities. Dentists who are not covered entities may

elect to obtain an NPI at their discretion, or may be enumerated if required by a

participating provider agreement with a third-party payer, or applicable state

law/regulation.

An NPI is unique to an individual dentist or dental entity, and has no intrinsic meaning.

There

are two types of NPI available to dentists and dental practices:

• Type 1 Individual Provider - All individual dentists are eligible to apply for Type 1

ADA Dental Claim Form Completion Instructions

Page 15 of 16

Completion Instructions Date: 2022Feb11

NPIs, regardless of whether they are covered by HIPAA.

• Type 2 Organization Provider - A health care provider that is an organization, such

a group practice or corporation. Individual dentists who are incorporated may

enumerate as Type 2 providers, in addition to being enumerated as a Type 1. All

incorporated dental practices and group practices are eligible for enumeration as

Type 2 providers.

On paper, there is no way to distinguish a type 1 from a type 2 in the absence of any

associated data; they are identical in format. Additional information on NPI and

enumeration

can be obtained from the ADA’s Internet Web Site –

National Provider Identifier

50.

License Number: If the billing dentist is an individual, enter the dentist’s license number. If a

billing entity (e.g., corporation) is submitting the claim, leave blank.

51.

SSN or TIN: Report the: 1) SSN or TIN if the billing dentist is unincorporated; 2) corporation TIN of

the billing dentist or dental entity if the practice is incorporated; or 3) entity TIN when the billing

entity is a group practice or clinic.

52.

Phone Number: Enter the business phone number of the billing dentist or dental entity.

52a. Additional Provider ID: This is an identifier assigned to the billing dentist or dental entity other

than a Social Security Number (SSN) or Tax Identification Number (TIN). It is not the provider’s

NPI.

The additional identifier is sometimes referred to as a Legacy Identifier (LID). LIDs may not be

unique as they are assigned by different entities (e.g., third-party payer; federal government).

Some Legacy IDs have an intrinsic meaning.

Treating Dentist And Treatment Location Information

This section must be completed for all claims. Information that is specific to the dentist or practitioner

acting within the scope of their state licensure who has provided treatment is entered in this section.

53.

Certification: Signature of the treating or rendering dentist and the date the form is signed. This is

the dentist who performed, or is in the process of performing, procedures, indicated by date, for

the patient. If the claim form is being used to obtain a pre-estimate or pre-authorization, it is not

necessary for the dentist to sign the form.

ADA Dental Claim Form Completion Instructions

Page 16 of 16

Completion Instructions Date: 2022Feb11

Claim forms prepared by the dentist’s practice management software may insert the treating

dentist’s printed name in this Item.

54.

NPI (National Provider Identifier): Enter the treating dentist’s Type 1 – Individual Provider NPI in

Item # 54. (See Item #49 for more NPI information.)

55.

License Number: Enter the license number of the treating dentist. This may vary from the billing

dentist.

56.

Address, City, State, Zip Code: Enter the physical location where the treatment was rendered.

Must be a street address, not a Post Office Box.

NOTE: For teledentistry encounters the treatment location is the dentist’s practice location,

not the patient’s location.

56a. Provider Specialty Code: Enter the code that indicates the type of dental professional who

delivered the treatment. Available codes describing treating dentists follow. The general code

listed as “Dentist” may be used instead of any other dental practitioner codes.

Category / Description Code

Dentist / a person qualified by a doctorate in dental surgery

(D.D.S) or dental medicine (D.M.D.) licensed by the state to

practice dentistry, and practicing within the scope of that license.

122300000X

General Practice / a dentist who provides a variety of dental

services to address patient needs.

1223G0001X

Dental Specialty

/ a practitioner in one of the nine specialty areas

recognized by the ADA.

See following list

Dental Public Health 1223D0001X

Endodontics 1223E0200X

Orthodontics 1223X0400X

Pediatric Dentistry 1223P0221X

Periodontics 1223P0300X

Prosthodontics 1223P0700X

Oral & Maxillofacial Pathology 1223P0106X

Oral & Maxillofacial Radiology 1223D0008X

Oral & Maxillofacial Surgery 1223S0112X

These codes are from the “Dental Service Providers” section of the Healthcare Providers

Taxonomy code list, a HIPAA standard, and are a subset of the full list that includes codes for

other types of practitioners including dental assistants, dental hygienists, denturists, and dental

lab technicians. The current full list is posted online –

Health Care Provider Taxonomy Code Set

57.

Phone Number: Enter the business telephone number of the treating dentist.

58.

Additional Provider ID: This is an identifier assigned to the treating dentist other than a Social

Security Number (SSN) or Tax Identification Number (TIN). It is not the provider’s NPI.

The additional identifier is sometimes referred to as a Legacy Identifier (LID). LIDs may not be

unique as they are assigned by different entities (e.g., third-party payer; Federal government).

Some Legacy IDs have an intrinsic meaning.