Appendix F. ADA Dental Claim Form Mapping

The mapping shown below provides guidance on how to populate the 837 Dental Claim from the ADA Dental Claim Form that was first published in 2005.

ADA Form Locator 1

Request for Predetermination/Preauthorization

2300 | CLM19 | 1383 / PB

ADA Form Locator 1

Statement of actual services

2300 | CLM19 | 1383 / (empty)

ADA Form Locator 1

EPSDT / Title XIX

2300 | CLM12

ADA Form Locator 2

Predetermination/Preauthorization Number

2300 | REF02 | 127 (REF01 = 'G1')

ADA Form Locator 3

Primary Payer Information

Name, Address, City, State, Zip Code

2010BB | NM103 | 1035

2010BB | N301 | 166

2010BB | N401 | 19

2010BB | N402 | 156

2010BB | N403 | 116

ADA Form Locator 4

Other Coverage

Other Dental or Medial Coverage (Yes)

2320 | SBR (is present)

ADA Form Locator 4

Other Coverage

Other Dental or Medial Coverage (No)

2320 | SBR (is absent)

ADA Form Locator 5

Other Coverage

Other Insured's Name (Last, First, Middle Initial, Suffix)

2330A | NM103 | 1035

2330A | NM104 | 1036

2330A | NM105 | 1037

2330A | NM107 | 1039

ADA Form Locator 6

Other Coverage

Date of Birth

N/A

ADA Form Locator 7

Other Coverage

Gender

N/A

ADA Form Locator 8

Other Coverage

Subscriber Identifier (SSN or ID#)

2330A | NM109 | 67

ADA Form Locator 9

Other Coverage

Plan / Group Number

2320 | SBR03 | 127

ADA Form Locator 10

Other Coverage

Patient's Relationship to Other Insured

2320 | SBR02 | 1069

ADA Form Locator 11

Other Coverage

Other Carrier Name, Address, City, State, Zip Code

2330B | NM103 | 1035

2330B | N301 | 166

2330B | N401 | 19

2330B | N402 | 156

2330B | N403 | 116

ADA Form Locator 12

Primary Insured Information

Name (Last, First, Middle Initial, Suffix, Address, City, State, Zip Code)

2010BA | NM103 | 1035

2010BA | NM104 | 1036

2010BA | NM105 | 1037

2010BA | NM107 | 1039

2010BA | N301 | 166

2010BA | N401 | 19

2010BA | N402 | 156

2010BA | N403 | 116

ADA Form Locator 13

Primary Insured Information

Date of Birth

2010BA | DMG02 | 1254

ADA Form Locator 14

Primary Insured Information

Gender

2010BA | DMG03 | 1068

ADA Form Locator 15

Primary Insured Information

Subscriber Identifier

2010BA | NM109

ADA Form Locator 16

Primary Insured Information

Plan / Group Number

2010BA | SBR03 | 127

ADA Form Locator 17

Primary Insured Information

Employer Name

N/A

ADA Form Locator 18

Patient Information

Relationship to Primary Insured

2010CA | PAT01 | 1069

2010BA | SBR02 | 1069

ADA Form Locator 19

Patient Information

Student Status

N/A

ADA Form Locator 20

Patient Information

Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code

2010CA | NM103 | 1035

2010CA | NM104 | 1036

2010CA | NM105 | 1037

2010CA | NM107 | 1039

2010CA | N301 | 166

2010CA | N401 | 19

2010CA | N402 | 156

2010CA | N403 | 116

ADA Form Locator 21

Patient Information

Date of Birth

2010CA | DMG02 | 1254

ADA Form Locator 22

Patient Information

Gender

2010CA | DMG03 | 1068

ADA Form Locator 23

Patient Information

Patient ID/Account # (Assigned by Dentist)

N/A

ADA Form Locator 24

Record of Services Provided

Procedure Date

2300 | DTP03 | 1251 (DTP01 = 472)

2400 | DTP03 | 1251 (DTP01 = 472)

ADA Form Locator 25

Record of Services Provided

Area of Oral Cavity

2400 | SV304-1 | 1361

ADA Form Locator 26

Record of Services Provided

Tooth System

2400 | TOO01 | 1270

ADA Form Locator 27

Record of Services Provided

Tooth Number(s) or Letter(s)

2400 | TOO02 | 1271

ADA Form Locator 28

Record of Services Provided

Tooth Surface

2400 | TOO03-1 | 1369

2400 | TOO03-2 | 1369

2400 | TOO03-3 | 1369

2400 | TOO03-4 | 1369

2400 | TOO03-5 | 1369

ADA Form Locator 29

Record of Services Provided

Procedure Code

2400 | SV301-2 | 234

ADA Form Locator 30

Record of Services Provided

Description

2400 | SV301-7 | 352

ADA Form Locator 31

Record of Services Provided

Fee

2400 | SV302 | 782

ADA Form Locator 32

Record of Services Provided

Other Fees

2400 | AMT02 | 782 (AMT01 = T)

ADA Form Locator 33

Record of Services Provided

Total Fee

2300 | CLM02 | 782

ADA Form Locator 34

Missing Teeth Information

2300 | DN201 | 127 (DN202 = M)

ADA Form Locator 35

Remarks

2300 | NTE02 | 352

ADA Form Locator 36

Authorizations - Release of Information

Signature

2300 | CLM09 | 1363

ADA Form Locator 36

Authorizations - Release of Information

Date

N/A

ADA Form Locator 37

Authorizations - Assignment of Benefits

Signature

2300 | CLM08 | 1073

ADA Form Locator 37

Authorizations - Assignment of Benefits

Date

N/A

ADA Form Locator 38

Ancillary Claim/Treatment Information

Place of Treatment

2300 | CLM05-1 | 1331

ADA Form Locator 39

Ancillary Claim/Treatment Information

Number of Enclosures (Radiographs)

N/A

ADA Form Locator 39

Ancillary Claim/Treatment Information

Number of Enclosures (Oral Images)

N/A

ADA Form Locator 39

Ancillary Claim/Treatment Information

Number of Enclosures (Model(s))

N/A

ADA Form Locator 40

Ancillary Claim/Treatment Information

Is Treatment for Orthodontics? (No)

2300 | DN1 (is absent)

ADA Form Locator 40

Ancillary Claim/Treatment Information

Is Treatment for Orthodontics? (Yes)

2300 | DN1 (is present)

ADA Form Locator 41

Ancillary Claim/Treatment Information

Date Appliance Placed

2300 | DTP03 | 1251 (DTP01 = 452)

ADA Form Locator 42

Ancillary Claim/Treatment Information

Months of Treatment Remaining

2300 | DN102 | 380

ADA Form Locator 43

Ancillary Claim/Treatment Information

Replacement of Prosthesis? (Yes)

2400 | SV305 | 1358 (SV305 = 'R')

ADA Form Locator 44

Ancillary Claim/Treatment Information

Date Prior Placement

2400 | DTP03 | 1251 (DTP01 = 441)

ADA Form Locator 45

Ancillary Claim/Treatment Information

Treatment Resulting From Occupational illness/injury

2300 | CLM11-1 | 1362 (CLM11-1 = 'EM')

2300 | CLM11-2 | 1362 (CLM11-2 = 'EM')

ADA Form Locator 45

Ancillary Claim/Treatment Information

Treatment Resulting From Auto Accident

2300 | CLM11-1 | 1362 (CLM11-1 = 'AA')

2300 | CLM11-2 | 1362 (CLM11-2 = 'AA')

ADA Form Locator 45

Ancillary Claim/Treatment Information

Treatment Resulting From Other Accident

2300 | CLM11-1 | 1362 (CLM11-1 = 'OA')

2300 | CLM11-2 | 1362 (CLM11-2 = 'OA')

ADA Form Locator 46

Ancillary Claim/Treatment Information

Date of Accident

2300 | DTP03 | 1251 (DTP01 = '439')

ADA Form Locator 47

Ancillary Claim/Treatment Information

Auto Accident State

2300 | CLM11-4 | 156

ADA Form Locator 48

Billing Dentist or Dental Entity

Name, Address, City, State, Zip Code

2010AA | NM103 | 1035

2010AA | NM104 | 1036

2010AA | NM105 | 1037

2010AA | NM107 | 1039

2010AA | N301 | 166

2010AA | N401 | 19

2010AA | N402 | 156

2010AA | N403 | 116

ADA Form Locator 49

Billing Dentist or Dental Entity

Provider ID

2010AA | NM109 | 67

2010AA | REF02 | 127

ADA Form Locator 50

Billing Dentist or Dental Entity

License Number

2010AA | REF02 | 127 (REF01 = '0B')

ADA Form Locator 51

Billing Dentist or Dental Entity

SSN or TIN

2010AA | REF02 | 127 (REF01 = 'EI')

2010AA | REF02 | 127 (REF01 = 'SY')

ADA Form Locator 52

Billing Dentist or Dental Entity

Telephone

2010AA | PER04 | 364 (PER03 = 'TE')

2010AA | PER06 | 364 (PER05 = 'TE')

2010AA | PER08 | 364 (PER07 = 'TE')

ADA Form Locator 53

Treating Dentist and Treatment Location

Signed (Treating Dentist)

2300 | CLM06 | 1073 (CLM06 = 'Y')

ADA Form Locator 53

Treating Dentist and Treatment Location

Date

N/A

ADA Form Locator 54

Treating Dentist and Treatment Location

Provider ID

2310B | NM109 | 67

2310B | REF02 | 127

ADA Form Locator 55

Treating Dentist and Treatment Location

License Number

2310B | REF02 | 127 (REF01 = '0B')

ADA Form Locator 56

Treating Dentist and Treatment Location

Address, City, State, Zip Code

2310C | NM103 | 1035

2310C | NM104 | 1036

2310C | NM105 | 1037

2310C | NM107 | 1039

2310C | N301 | 166

2310C | N401 | 19

2310C | N402 | 156

2310C | N403 | 116

ADA Form Locator 57

Treating Dentist and Treatment Location

Phone Number

(Loop 2310B Rendering Provider not present)

2010AA | PER04 | 364 (PER03 = 'TE')

2010AA | PER06 | 364 (PER05 = 'TE')

2010AA | PER08 | 364 (PER07 = 'TE')

ADA Form Locator 58

Treating Dentist and Treatment Location

Treating Provider Specialty

2310B | PRV03 | 127

2000A | PRV03 | 127