Assistance Program must use the ADA 2006 claim form (J400). ADA Dental Claim Form Instructions Header Information Data Element 1 - Type of Transaction: Dental Claim Billing Standard - J400 v3.1approved; This standard adopts the ADA Dental Claim Form J400 as the only official Paper Dental Claim for paper claims. Downloadable version of the ADA Dental Claim Form allows immediate access and requires no shipping. Includes blanks for the National Provider Identifier (NPI), as Alabama public employees receiving supplemental dental coverage administered by Southland Benefit Solutions can use the claim form discussed in this article. ADA Dental Claim Form X X George Young, DDS NPI2 Billing Ent Lic Billing Entity 2202 Althoff Drive, P.O. Box 1267 Anytown, IL 99999 (555) 555-5555 Federal Tax ID Find best value and selection for your ADA Dental Insurance Claim Forms J400 search on eBay. World's leading marketplace. ADA Dental Claim Form (version J400) Instructions. Field Number 58: Additional Provider ID refers to the non-NPI number of the treating dentist. This is Dental Claim Form 1. Type of Transaction (Check all applicable boxes) EPSDT/Title XIX HEADER INFORMATION OTHER COVERAGE Statement of Actual Services - OR Alabama ADA Dental Claim Form Step 11: In box 11, enter the name, address, city, state and zip code of the other insurance company or dental benefit plan.
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