The ADA dental claim form is the standard paper form for reporting dental services to an insurance plan, maintained by the American Dental Association, with 58 numbered fields. The current version is the 2024 form. This guide walks every field that matters, shows where claims go wrong, and explains how the paper form relates to its electronic twin, the 837D.
Last updated June 2026 · Reviewed by the PracticeAlpha billing team
It is the one form the whole industry agreed to use. The American Dental Association created it so a dentist could report treatment to any payer in a single, predictable layout. Every commercial carrier, most Medicaid programs, and the dental side of Medicare accept it.
The ADA's Council on Dental Benefit Programs owns the content. Staff inside the ADA's Practice Institute maintain the paper form and its completion instructions. By ADA policy the form's data must stay in harmony with the HIPAA standard electronic claim, so paper and electronic carry the same information.
The form has 58 numbered items. They run in groups: the header, the payer, other coverage, the subscriber, the patient, the record of services, authorizations, ancillary details, the billing dentist, and the treating dentist. The groupings are not decoration. A field's meaning shifts depending on whether the claim is going to the primary or the secondary carrier.
The 2024 ADA Dental Claim Form took effect January 1, 2024. It did not remove anything from the 2019 form. It added four fields, and both versions are still accepted and can be submitted interchangeably.
Box 19 (formerly Student Status) is now Reserved For Future Use. Leave it blank.
Box 1, Type of Transaction, decides what the whole form does. Mark "Statement of Actual Services" if the treatment already happened. Mark "Request for Predetermination / Preauthorization" if you want the payer to estimate coverage first. There is also an "EPSDT / Title XIX" box for the Medicaid screening program.
Box 2 is the predetermination or preauthorization number. If the payer already pre-authorized the procedure, drop that number here so the claim links back to the approval.
Box 3 names the payer receiving this claim: company, address, city, state, zip. This box is always completed. When the patient has two plans, the primary carrier goes here on the first submission. On the secondary claim, the secondary carrier's name and address go in Box 3 instead.
Box 3a is the new Payer ID, a routing code for the carrier in Box 3. Leave it blank if you do not know it. Getting verification right before any of this matters more than the form itself, which is why solid dental insurance verification is the real first step in a clean claim.
This block exists for coordination of benefits. Here is the trick that trips people up. On a claim going to the primary carrier, the "Other Coverage" section describes the secondary plan. On a claim going to the secondary carrier, it describes the primary. Other Coverage always means "the plan that is not in Box 3."
Box 4 asks whether other dental or medical coverage exists. Mark "Dental?" or "Medical?" Leave it blank only if you are genuinely unaware of any other plan. If you mark a box, fill in Boxes 5 through 11. If both dental and medical apply, describe the dental plan there.
Boxes 5 to 11 carry the other policyholder: name (Box 5), date of birth (Box 6), gender (Box 7), the plan-assigned subscriber ID (Box 8), the group number (Box 9), the patient's relationship to that person (Box 10), and the other plan's name and address (Box 11). Box 11a is the Other Payer ID.
Boxes 12 to 17 describe the subscriber of the plan in Box 3, who may or may not be the patient. Box 12 is name and address. Box 13 is date of birth, eight digits. Box 14 is gender. Box 15 is the plan-assigned subscriber ID, the single field carriers check first. One wrong digit and the claim bounces. Box 16 is the group number, Box 17 the employer name.
For more on stacking two plans correctly, see our guide to secondary dental insurance and coordination of benefits.
Box 18 marks the patient's relationship to the subscriber in Box 12. If the patient is the subscriber, mark "Self" and skip straight to Box 23. The relationship can change what benefits are available, so it matters.
Box 19 is Reserved For Future Use. It used to hold Student Status. Leave it blank.
Box 20 is the patient's name and address. Box 21 is the patient's date of birth, again eight digits: two for month, two for day, four for year. Box 22 is gender. Box 23 is an optional patient or account number the office assigns. It is not required to process the claim.
This is the heart of the form. Boxes 24 through 31 repeat across 10 service lines, one row per procedure. Get a single cell wrong here and the line denies. The fields below do not repeat: 32, 33, 34, and 35.
Box 36 is patient consent, and Box 37 authorizes the payer to send benefits directly to the dentist. Practice software usually prints "Signature on File" in both when the signatures are on record.
Box 38, Place of Treatment, takes a two-digit CMS Place of Service code. 11 is office, 12 home, 21 inpatient hospital, 22 outpatient hospital, 02 teledentistry. For a teledentistry visit the location is the dentist's office, not the patient's.
Box 39 flags enclosures with a Y or N, telling the payer whether radiographs, images, or models are attached. Box 39a, new in 2024, is the date of the last scaling and root planing. Missing attachments that you said were coming, or forgot to flag, are a quiet denial driver.
Boxes 40 to 42 cover orthodontics: whether the treatment is ortho, the appliance placement date, and total months of treatment. Boxes 43 and 44 cover prosthetics. If you are replacing a crown, bridge, or denture, mark "Yes" in Box 43 and put the prior placement date in Box 44. Skip that date and a replacement claim often denies.
Boxes 45 to 47 capture accident details: whether treatment resulted from an accident, the date, and the auto-accident state.
Two separate parties, two separate sections. The billing entity gets paid. The treating dentist did the work. They are often the same person, but not always, and the payer needs both.
Leave 48 to 52a blank only if the patient is filing the claim themselves.
This section is required on every claim. If a locum did the work, 54 to 58 are the locum's details.
A predetermination does not need the Box 53 signature. The billing NPI in Box 49 and the treating NPI in Box 54 are different identifiers, and mixing them up is a classic rejection cause.
The paper ADA form and the electronic 837D carry the same data. ADA policy requires it. The difference is shape. The 837D is a HIPAA EDI transaction built from data loops and segments, not from numbered boxes you can see on a page.
Almost no one mails paper anymore. Practice management software builds the claim, a clearinghouse scrubs it, and it lands at the payer electronically. Electronic claims process faster, get rejected less, and skip the stamp.
Paper still has its place. Some claims need physical attachments, some small or out-of-network payers prefer it, and an appeal sometimes goes back on paper with documentation. As of mid-2024, dentists can also submit Medicare dental claims electronically, which closed one of the last big paper gaps.
Either way, the box logic above is what your software is filling in behind the scenes. Understanding the boxes makes the rejections readable. If denials are piling up across your panel, structured claims and AR recovery work usually finds the same handful of field errors repeating.
Most denials are not exotic. They are the same small data errors, over and over.
A name, date of birth, or member ID in Boxes 12 to 15 that differs from the payer's records. The single most common cause of a delayed or denied claim.
Type 1 where a Type 2 belongs, the treating NPI in the billing slot, or a blank Box 51. Identifier errors reject before a human ever sees the claim.
A CDT code with no tooth number, no surface, or no quadrant when the code requires one. Perio and implant codes are the usual offenders.
Box 39 says enclosures are coming, or a code needs a narrative or X-ray, and nothing arrives. The line stalls in review.
Box 43 marked "Yes" but Box 44 left blank. The payer cannot confirm the replacement is covered, so it denies.
Past the payer's timely-filing window, which can be 12 months, 180 days, or as short as 90. A perfect form filed late still gets denied.
The American Dental Association is the source. The ADA Catalog sells blank printable PDFs and pre-printed laser stock, and ada.org posts an image of the current form along with the full completion instructions for all 58 items.
If you run practice management software, you already have it. The software generates a populated 2024 ADA form and feeds the matching 837D to your clearinghouse. You rarely touch a blank form by hand.
Many payers also host a downloadable copy on their provider portals, which is handy for one-off paper submissions and appeals. Just confirm it is the 2024 layout so the new fields are present.
The standard paper claim form for reporting dental services to a benefit plan, created and maintained by the American Dental Association. It has 58 numbered fields covering the payer, the subscriber, the patient, the procedures, and the billing and treating dentists. Its data must stay in harmony with the HIPAA electronic dental claim, the 837D.
The 2024 ADA Dental Claim Form, effective January 1, 2024. It added four fields to the 2019 version: 3a Payer ID, 11a Other Payer ID, 39a Date of Last Scaling and Root Planing, and 53a Locum Tenens Dentist. The 2019 version is still accepted, and the two can be submitted interchangeably.
They carry the same data, but the 837D is a HIPAA EDI transaction built from data loops rather than numbered boxes. ADA policy requires the paper form's content to match the 837D. Most practices submit electronically through a clearinghouse, which is faster and has fewer rejections than mailing paper.
In Box 28, using single letters with no spaces: B buccal, D distal, F facial or labial, I incisal, L lingual, M mesial, O occlusal. A three-surface filling is written MOD. Only fill the box when the procedure involves specific tooth surfaces.
The dentist's full fee for the procedure. Per ADA policy, a contractual relationship with a payer does not change the full fee, and it is always appropriate to report the full fee. Box 32 is the sum of all line fees plus any other fees in Box 31a.
Box 1 sets it. Mark Statement of Actual Services for work already done and include procedure dates in Box 24. Mark Request for Predetermination or Preauthorization to estimate coverage before treatment, and leave the procedure dates blank. A predetermination is not a guarantee of payment.
Mismatched subscriber name, date of birth, or member ID; missing or wrong NPI or TIN; the wrong CDT code or a code without the required tooth, surface, or quadrant; missing attachments noted in Box 39; a prosthetic replacement without the prior placement date in Box 44; and filing past the payer's timely-filing deadline.
The American Dental Association sells printable and pre-printed versions and posts the form image plus completion instructions on ada.org. Practice management software generates a populated copy automatically. Many payers also host a downloadable copy on their provider sites.
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