American Dental Association (ADA) Claim Form 2012

Please share this information with Clinical, Coding, Billing, and IT Staff

Effective October 1, 2013, the Department will no longer accept the 1994, 1999, and 2002 versions of the American Dental Association (ADA) Claim Form. The 2006 ADA claim form will continue to be accepted through December 31, 2013.

Effective January 1, 2014, the 2012 ADA claim form will become the only hardcopy dental claim form accepted by the Department for prior authorizations and reimbursement of services.

Instructions for completing the ADA 2012 claim form are located on our website (see Manual Letter #61-2013 @ 

The ADA manual can be found at

Please note that on or after January 1, 2014, any claims received utilizing the older versions of the ADA Claim Form will be returned to the provider.

To meet the January 1st requirement:

Hardcopy billing providers currently using older versions of the ADA claim form should request the 2012 version from the ADA as soon as possible.

Providers who are using dental software to print older versions of the hardcopy dental claim forms should contact their software vendor as soon as possible.

For questions regarding this information, please contact John Naujokaitis at  or 402-471-6353.

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